Conversation Starter: 'Repeal of the Job-Killing Health Care Act' - Part II?
The House vote to repeal what critics call "Obamacare" (the Patient Protection and Affordable Care Act - ACA -- signed by President Obama on March 23, 2010) was a key part of the GOP campaign to win back the House of Representatives in the November elections. It worked as an effective mobilizing call to arms.
HR2 (Repeal of the Job-Killing Health Care Act) passed the House by a vote of 245 to 189 on January 19, 2011. The Senate, however, killed the bill February 2, and the issue receded to a background murmur. Republicans and Democrats have drawn their swords over the President's budget, instead.
Still, repealing the health care act is likely to return to the political agenda. House Speaker John Boehner (R-Ohio) states that "The Congress can do better in terms of replacing Obamacare with common sense reforms that will bring down the cost of health insurance and expand access for Americans."
To assess such a proposition, one would have to know more details about his party's solutions. But proposals so far are conspicuously absent.
After Congress passed the ACA, Boehner called it a "dangerous experiment." Texas Gov. Rick Perry called it "socialism on American soil." Many of their Republican colleagues have reread the script used by the American Medical Association (AMA) in opposing extensions of health insurance coverage propounded by President Franklin Roosevelt, Harry Truman, Lyndon Johnson and Bill Clinton. They suggest that the ACA will result in a "government take-over" of American medicine, at worst, and "government-run" health care, at best.
But such attacks are dangerously misleading because they distort present realities and generate ill-founded fears.
We already have a massive government role in American health care; and for good reasons. We have socialized expenditures for our highest-risk populations - the elderly and severely handicapped (Medicare) and for the very poor (Medicaid) -- and we have a system of socialized medicine for our military veterans, which delivers health care of higher quality than what is received by the average American.
At the same time, most health care in the U.S. is provided by private non-profit hospitals and private doctors reimbursed on a fee-for-service basis. Clinical decisions remain largely in the hands of our physicians and to the extent that there has been increasing intervention and regulation of these decisions, it has come most forcefully from private insurance companies. Meanwhile, we have more government expenditure of biomedical research (NIH) and public health (CDC) than any nation in the world. And the system produces staggering rates of innovation in pharmaceutical research, medical devices and medicine.
The ACA is largely a bipartisan, half-way reform strategy inspired more by former Republican Governor Mitt Romney of Massachusetts than by left-leaning advocates of single-payer health insurance reform. It does not nationalize the health insurance industry. It does not increase the share of public hospitals. It does not set uniform prices for hospital and physician payment across all payers. And it does not assure universal coverage.
At best, the ACA, if implemented in 2014, will begin to increase coverage to 32 million of the more than 50 million Americans who are currently uninsured. It will achieve this objective through Medicaid expansion and the creation of health insurance exchanges that will strengthen federal regulation of the private health insurance industry through the prohibition of risk selection by insurance companies (the ban on refusals to cover pre-existing conditions and to set annual and life-time limits on coverage).
Finally, the ACA, passed before the extension of the Bush tax cuts for the wealthiest Americans, begins to reverse the post-Reagan policies of increasing income inequalities. It does so by increasing the existing Medicare payroll tax on all those earning over $200,000 ($250,000 for couples).
These are significant, but modest, steps toward what political scientist Jo White calls the "international standard" among health systems in wealthy capitalist democracies - Japan, Germany, France, United Kingdom, Canada, Switzerland, Australia, Netherlands, and many more.
This standard, met by all governments in such nations, either imposes taxes on its citizens or enforces a health insurance mandate to provide access to a minimum level of health care services. Without taxes or a mandate, there can be no universal health insurance coverage. Without universal health insurance coverage, we cannot meet the international standard.
Conversation Starter: Mayor Bloomberg's Bid to Ban Soda Purchases with Food Stamps
Mayor Michael Bloomberg has long made it a paramount goal to rid New York City of unhealthful foods, and he recently asked the Federal government for permission to prohibit Food Stamp recipients from using stamps to buy soda and other sugared beverages in the city.
Supporters are cheering Bloomberg’s stance, saying he’s striking a blow for better dietary habits and ultimately lower public health costs and consequences such as obesity. But critics question the move, seeing it as an example of big government, even patronizing toward the poor.
Research can be a valuable guidepost for public officials. In 2009, after Mayor Bloomberg required restaurant franchises to put calories counts on their menus, NYU Wagner professors Rogan Kersh and Brian Elbel sought to measure the impact of the calorie labeling initiative on consumer habits at fast-food restaurants in low-income neighborhoods. Their survey of 1,156 adult found little direct evidence to support the Mayor’s view that the posting of calorie counts causes fast-food patrons to buy items containing fewer calories. Elbel’s and Kersh’s widely discussed study, published in the journal Health Affairs, emphasized that follow-up studies are needed to determine the value and effectiveness of menu labeling and other obesity-related policies.
Professor Elbel describes the Mayor’s current proposal to prohibit the use of food stamps for the purchase of soda and sugary drinks as “an extremely innovative policy approach to tackle the complicated and multifaceted problem of obesity. It deserves a rigorous assessment, to evaluate its overall impact on healthy food choice and obesity,” says Professor Elbel, assistant professor of medicine and health policy. “The rest of the nation can then learn from the New York City experience as these and other policies to fight obesity are considered across the country.”
What’s your opinion of the Mayor’s food stamp initiative? Is it good public policy? Or should it just be allowed to fizzle out? Visit Wagner’s Public Service Today blog to post your comment today.
Conversation Starter: Thoughts for the New NYC Schools Chancellor, Cathie Black
Amy Ellen Schwartz writes:
Cathie Black's appointment as New York City Schools Chancellor came at a difficult period. While her predecessor, Joel Klein, enjoyed swelling public coffers and large increases in per-pupil spending, Chancellor Black takes office at a time when the budget is shrinking, certainly significantly and maybe substantially.
At the same time, while Chancellor Klein claimed standardized test results "proved" his reforms were working, the recent adjustments in those metrics have fueled doubt about whether - and to what extent - his hallmark strategies such as replacing large comprehensive high schools with new, small schools and increasing school autonomy "worked." Even more, the turmoil created by opening and closing schools - and the attendant expense - raises questions about the sustainability of these reforms.
Bottom line: Cathie Black faces considerable challenges in the months ahead and it behooves us to help her succeed. In that spirit, I offer the following suggestions.
Beyond "What Works": While education officials and policy makers tout the importance of finding out "what works," we need more than that. We need to figure out "what's worth the money" or what gives the biggest bang for the public buck. Is the high cost of new small schools worth the money, or would we do better to invest in mid-size schools or schools-within-schools? Unfortunately, relatively little attention has been paid to the costs of interventions and reforms and so the evidence base is thinner than it should be. This is a gap that needs to be filled.
Special Education is Critical: Between 2002 and 2008, full-time special education students increased by 20 percent, from just over 82,000 to over 98,000. (That's an increase from 7.5 to 9.5 percent of total enrollment.) At the same time, direct per pupil expenditures for special education increased 31 percent. Together, this means that Special Education eats up a larger and larger share of the budget, threatening to crowd out spending and services for general education students. (My forthcoming paper with Leanna Stiefel provides more detail.) While federal and state rules and regulations place significant restrictions on classification, services, and so on, the school district can and must find ways to deliver required services in the most cost effective way possible.
Don't overestimate the value of value-added: Although evaluating the efficacy of teachers and schools using test score based value-added measures has undeniable intuitive appeal, the usefulness of these measures in improving schools now is much more limited than the publicity might suggest. For one thing, value-added measures can only be calculated for a fraction of teachers in NYC public schools. (Currently, only about one in five.). More importantly, however, it seems unlikely that value-added scores will identify significant numbers of previously unidentified "bad teachers" that can then be dismissed to make way for (or save the jobs of) otherwise-hidden "great teachers." I am certain that value-added analyses have an important role to play in education policy and practice in the long run - and equally confident that the short-run returns will be fairly small.
Moving Matters: Chancellor Klein was fond of saying that much of his reform efforts were guided by a desire to create a system of good schools and not a good school system. In practice this meant that accountability fell to individual schools for the students currently enrolled. Who, then, is responsible for making sure that students enroll in schools that can provide the services they need? That they choose "well"? In a different vein, a growing body of research shows that student mobility between schools - prompted, say, by family dissolution, foreclosure, or behavioral or academic problems - harms their performance and, potentially, affects their peers. Helping students navigate between schools, adjust to new environments, and succeed will mean attention and accountability for the school system and not just a collection of good schools.
One of my colleagues once claimed that every home in New York City was within walking distance of one of the best public schools in the country...and one of the worst. As a parent and alum of the New York City public schools, I wish Cathie Black the best of luck in her effort to make all of our schools better.
Stiefel, L., Schwartz, A. E. (2011). "Financing K-12 Education in the Bloomberg Years, 2002-2008" in Jennifer A. O'Day, Catherine S. Bitter and Louis M. Gomez (Eds.), Education Reform in New York City: Ambitious Change in the Nation's Most Complex School System (pp. 55-84). Cambridge MA: Harvard Education Press.
Stiefel, L., Schwartz, A. E., Conger, D. (2010). "Age of Entry and the High School Performance of Immigrant Youth." Journal of Urban Economics, 67:303-314.