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For some forty years before this week’s government shutdown the governing class in the U.S., Democrats and Republicans, has been playing ‘good cop, bad cop’ with public policy. Lest we forget, the bi-partisan cuts in public spending under sequestration were already underway when the current partial government shutdown began. And the disinformation campaign by Republicans against ‘Obamacare’ only serves to shift that wholly inadequate debacle into the realm of ‘reasonable’ in the spectrum of public policy debate. In fact, getting liberals and progressives to heartily endorse health care ‘reform’ designed by the right-wing Heritage Foundation with the intent of precluding universal health care ties to the decades old move rightward by ‘liberal’ Democrats under the guise of pragmatism. Democrats play the good natured but ineffectual sops—the good cops, while Republicans play the crazies with their guns to our foreheads to divert attention away from the fact that actual policy differences between the two are but marketing ploys.
The economic pain caused the poor and vulnerable by the government shutdown is real. But the assertion that Democrats object to this is ludicrous on its face. President Barack Obama has spent his last five years in office studiously ignoring the plight of the poor and unemployed while he has actively pursued policies that benefit America’s richest through unconditional bailouts of corrupt bankers, mortgage ‘settlements’ that allowed banks to steal the entirety of accumulated black wealth, secret trade agreements (TPP– Trans-Pacific Partnership) that reconstitute predatory political economy and intricate state spying on citizens by the NSA to secure and maintain corporate-state control over us. President Bill Clinton before him ended ‘welfare as we know it’ without providing offsetting economic empowerment for America’s most vulnerable, ‘freed’ the banks to destroy the global economy, brought to fruition the NAFTA ‘free-trade’ agreement that has decimated middle class jobs and he pushed for cuts to Social Security. The illusion that the plight of the poor and vulnerable is a lever to which the political class will respond is now forty years past its expiration date.
For those who haven’t spent much time with the details of Obamacare, the ACA (Affordable Care Act), the devil features prominently in them. With all due deference to the vulgarity of the metaphor, its basic premise is that by lowering the cost of a yacht (health care) from $100,000 to $50,000 through subsidies the yacht will become more affordable. Poor people, and America has a whole lot of poor people, are given the choice of buying the yacht at a subsidized price—subsidies for health insurance premiums, deductibles and co-pays that many still can’t afford, or of paying a fine. Even where the fine approximates the cost of the (subsidized) health insurance premium getting actual health care requires paying additional (subsidized) deductibles and co-pays beyond the ability of many poor people to pay. The subsidized yacht may be cheaper than the yacht without subsidies but it still isn’t affordable. Recourse for health care denied remains where it was—first through appeal to the same health insurers doing the denying and then to the same private, state or Federal agencies that have been wholly ineffectual at forcing insurers to pay legitimate claims for decades. For those unaware, the insurance industry has spent the last twenty years perfecting the art of not paying legitimate claims.
Much of the content of the ACA is written as if by a dull eighth-grader trying to bullshit his or her way through an exam in school. ‘Free preventative services’ are screens for which ‘consumers’ pay a deductible where applicable and any remedy when problems are found—say the diabetes screen shows the presence of diabetes, is pay as you go under the terms of the ACA. While the screens may alert people to problems, doing so is of little value unless they can afford to buy the follow-on health care. And it appears little effort was expended estimating the distance between ‘less costly’ health care and health care that is affordable. The subsidies under the program look impressive until the cost of required health insurance plus health care is related to how little ‘disposable’ income poor people have. More fundamentally, and the reason for the vulgar ‘yacht’ metaphor, the whole approach to health care under the ACA leaves it at the level of capitalist ‘desire’ rather than as the basic human need it is. As ‘desire’ the material circumstance of poverty becomes the ugly right wing fantasy that 1) the poor choose to be poor therefore 2) the deprivations of poverty are ‘market’ choices and 3) the poor would have health care under the ACA if they would only work / earn more and spend their money on health care rather than on drink and drugs. The ACA is at its core health care social Darwinism with the façade of compassion.
More broadly, the U.S. has the most expensive healthcare system in the ‘developed’ world and still it only provides about two-thirds of the benefits of other systems at twice their price. The argument that under Obamacare ‘competition’ among health insurers will bring costs down ignores both that these insurers are already expert at reducing costs by denying coverage for legitimate medical claims and that any true interest in medical market competition would include doctors, pharmaceutical companies and medical device manufacturers through the elimination of restrictions on the number of doctors that can be accredited, by reducing or eliminating patents on medicines and by breaking up anti-competitive medical device cartels. None of these are part of Obamacare and were ‘market competition’ a viable solution the current system wouldn’t exist. Without bringing health care costs in line with functioning health care systems the subsidies that are being advertised as a way to provide health care to the poor are largely just more corporate welfare for the medical and health insurance industries. And with a number of states opting out of Medicaid expansion millions of poor, largely black and Hispanic, citizens will see no benefit from the ACA.
This latter point was taken up by the New York Times without mention that Mr. Obama’s purported rationale for not only not considering, but openly mocking ‘Medicare for all,’ the ‘public option,’ was that his plan was politically feasible. As it turns out, and with help from a Supreme Court known to be a dim shill for the corporate-state, the ACA is not politically feasible for substantial numbers of the people who need health care the most. As was known when the ACA was being proposed, many local and state governments have been populated with corporate-state operatives and are but conduits for legislation written by ALEC (American Legislative Exchange Council). The Supreme Court ruling to defer decision on Medicaid expansion to the states has been known to proponents of the ACA since it was handed down in 2012. And whereas it might be tempting to assign responsibility for this ‘failure’ on Republican obstructionism 1) ‘Medicare for all’ was a real possibility when Democrats held the White House and both Houses of Congress as the ACA was being debated, 2) Mr. Obama himself has been an aggressive shill for the likes of ALEC through his corporate-friendly policies (TPP, bank bailouts, secret deal with health insurers to forgo Medicare for all) and 3) state intransigence on Medicaid expansion serves the same function as belligerent Republicans in positioning the ACA as something other than a right-wing effort to preclude universal health care.
Being only microscopically facetious, in the context of the rollout of the ACA three and one-half years after it was passed the Congressional Republicans behind phony right-wing critiques of Obamacare are either on the White House payroll directly or have struck a deal with Mr. Obama to cut Social Security and Medicare as Mr. Obama agreed to do during the last ‘debt-ceiling’ charade. To be clear, knowingly portraying Obamacare as a socialist takeover of the health care system, as Congressional Republicans have done, is a public relations coup for Mr. Obama in that it sells his plan designed to preclude universal health care as its opposite to a population in desperate need of a functioning health care system. Economist Paul Krugman’s hypothesis that Republicans are resisting Obamacare because they are afraid it might work ignores that it is a Republican plan designed by right-wing strategists to preclude universal health care and was first implemented in Massachusetts by Republican Governor Mitt Romney. The more probable hypothesis is that Americans could have gotten Obamacare passed and implemented without all the bullshit by electing a Republican in favor of the program President.
Theory aside Romneycare–the template for the ACA, has been the law in Massachusetts since 2006 and as measured across different dimensions—the relative rise in health insurance premiums, the change in the quantity of health care provided and the number of people insured, the only unambiguous result is that when people are required to buy health insurance the number of people who have health insurance increases. Health care ‘usage’ in Massachusetts should have surged with the passage of Romneycare if the number of insured were materially related to those who receive health care. But the actual results are ambiguous with not enough difference one way or the other for strong claims to be made. Since 2006 health insurance premiums have risen a bit less in Massachusetts than they have throughout the rest of the country. But the cost and quantity of health insurance is only relevant to discussion of health care as it directly relates to it. The factors driving medical cost inflation, the AMA (American Medical Association) restriction on the number of accredited doctors, monopoly patents on pharmaceuticals and the power of medical device cartels have been unaffected by Romneycare. And when I moved from Cambridge, MA in 2010 the local news was full of stories of the state removing people from the program to reduce costs.
Many liberals and progressives are defending the ACA as the last, best hope for substantive health care reform in the U.S. But with the public realization that under the ACA nine million or more of the nation’s poorest—largely southern blacks and Hispanics, won’t receive any benefit from the program the question remains as it has since Democrat Jimmy Carter occupied the White House—how low are you willing to go? The ACA is a corporate-state creation designed to insure only that the insurance-medical establishment remains at the center of America’s health care denial industry. Massachusetts was the ideal ‘proof of concept’ for Obamacare because it already had a high rate of citizens with health insurance and a developed health care infrastructure. But the only certain result of Romneycare is that having health insurance is at best weakly related to receiving health care. By retaining the profit driven system it is only a matter of time before campaign contributions and the industry tilt of official Washington turn the ACA into an even worse pile of shit than what preceded it. Who is going to make the insurance companies do what Mr. Obama says they will do? How many millions of human beings are going to suffer in misery and destitution because the nation’s health care system remains ‘private?’
The strategic stupidity of the U.S. left, such as it is, is in allowing the radical right to continue to rule through engineered crises. Two points—through the last forty year’s trajectory toward radical-right political economy our circumstance has become a permanent crisis regardless of the theater du jour in Washington. Second, if the right is willing to create crises to assert its policies this is fact that needs to be considered in the context of a larger strategy, not responded to. Political class Democrats are fine with this state of affairs because it ‘legitimates’ their move to the radical right—where the money is, that otherwise might be visible to Democrat supporters. A left strategy should encompass this understanding and use the crises created by the right to direct the results rather than giving away the store to avoid them. To be clear, the ACA derives from the same political program as the bank bailouts, the TPP, NSA spying, drone murders and the privatization of public resources. President Barack Obama and the Democrats have spent the last five years screwing poor and working people for the benefit of their corporate masters. Even were their intentions good, a dubious proposition, it is their policies that matter and the policies are the problem. The absence of meaningful employment for all, true democratic participation in political economy, high quality health care and education for all and food and housing security is a crisis irrespective of what the right says or does. If the right and the political establishment want a crisis we should give them one.
Rob Urie is an artist and political economist in New York. His book Zen Economics will be published by Counterpunch / CK Press in Spring 2014.