Americans use patriotism as a political cudgel. Lincoln had an answer to that problem.
There has long been an argument, roughly along the axis of conservatism and progressivism, about whether to love America for what it has been or what it should be. The right inclines to American exceptionalism, and the sense that our nation’s roots in self-evident moral truths render it a unique force for good in the world and make its politics distinctly elevated. The left inclines to a more redemptive hope in America — the idea that our country has been working from its birth to overcome its unique sins, and that it has made some progress but has much more to make... Liberals argue that the conservative form of patriotism sanitizes history and descends into jingoism. Conservatives say the left’s form of patriotism isn’t so much a regard for America as for liberal political ideals, which progressives hope our country might increasingly come to resemble... What stands out about America, Trump argues, is not its ideals or its gradual self-improvement but the simple fact that it is our country. So America’s leaders should do what the leaders of all other nations do and put their own nation first... Each camp understands its adversaries as speaking somehow from outside that tradition and perhaps against it. So patriotism itself becomes a source of disunity... One man’s life and thought were a testament to all three forms of patriotism. Abraham Lincoln .. his thinking on that subject offers a model of genuine statesmanship, because it tended to build bridges where others, in his time and ours, could see only chasms... Our idealistic exceptionalism is, if anything, a restraint on self-congratulation because it always compels us to confront the fact that we fall short of our ideals. The American creed, Lincoln argued in one speech, should form “a standard maxim for free society, which should be familiar to all and revered by all.. progress toward justice involves vindicating rather than repudiating our founding principles... Memory is both conceptual and visceral. It lets us take pride in our ideals and our experience — our origins and our progress — and the fact that both are ours... America is not itself an ideal but a real nation, full of real people who deserve leaders who put them first.
AEI: Improving Health and Health Care: An Agenda for Reform
Those Americans without access to employer coverage should be given a refundable, age-adjusted tax credit that is set roughly equal to the average tax break for an employer plan.
.. This rule would protect persons with preexisting conditions from being charged more, or denied coverage, based on their health status so long as they have not experienced long breaks in insurance enrollment
.. States could also boost insurance enrollment by assigning persons who are eligible for the tax credits but have failed to pick an insurance policy to a default insurance plan. The upfront deductibles for these insurance plans would be set as necessary to ensure the premiums for enrollment would be equal to the federal tax credit, thus ensuring no additional premium would be required from a person assigned to a default plan.
.. Reform of Medicaid must start with changing how the federal government pays for its share of total cost. The program should be divided into its two distinct subparts, one for able-bodied adults and their children and the other for the disabled and elderly.
.. Medicare’s rules for paying hospitals, physicians, and other service providers heavily influence how care is delivered to all patients, not just Medicare enrollees. The program would improve if there were fewer regulations and more emphasis on market-based reforms. The starting point should be conversion of the program, on a prospective basis, to a premium support model
.. HSAs should be a central component of health care in the United States. The accounts provide strong incentives for their owners to seek the best value for their health care purchases, and they provide a ready vehicle for providing additional protection against high medical expenses.
.. A comprehensive reform plan should also reform the health insurance benefit for federal employees so that it operates like a defined contribution program.
Principles for Reform
- Citizens, not government, should control health care.
- Government subsidies should come in the form of defined contribution payments.
- Move power and control from the federal government to individuals, families, and states.
- Suppliers of medical services must have more freedom to innovate and provide better services to patients and consumers.
- Reform must improve the federal fiscal outlook by reducing long-term health obligations.
The Good, the Bad, and the Senate Health-Care Bill
It is a function of some things they’ve come to prioritize about the individual health-insurance market and Medicaid, and some things they’ve learned about the intricacies of the Byrd rule and Senate procedural constraints.
.. After seven years of saying they want to repeal and replace Obamacare, congressional Republicans have been forced to confront the fact that many of them, perhaps most, actually don’t quite want to do that.
.. That doesn’t mean that most of them never did. The case for repeal was strongest in the three or four years between the enactment and implementation of Obamacare. As more time passes since the beginning of implementation three and a half years ago, and more people’s lives become intertwined with the program for good and bad, the case for addressing Obamacare’s immense deficiencies by repeal weakens
.. I still think it is very much the case that the cause of good policy (almost regardless of your priorities in health care) would be better served by a repeal and replacement, with appropriate transition measures, than by this sort of tinkering — you’d get more coverage, a better health-financing system, and a more appropriate role for government.
.. The president has been an additional unpredictable political constraint — as the more coherent of his musings on health care have all suggested he is not comfortable with repealing and replacing the law, or at least is unfamiliar with the tradeoffs involved and unhappy when he learns about them.
.. But another thing Republicans have learned in these six months is that Donald Trump is an exceptionally weak president, probably the weakest of their lifetimes, and he is likely to accept whatever they do. He’ll celebrate it, sitting himself front and center while they stand around him awkwardly. He’ll praise it wildly and inaccurately. And he’ll sign it — even if pretty soon thereafter, in the wake of bad press, he tries to distance himself from it on Twitter and calls them names.
.. It is pegged to a less comprehensive insurance model and will both cost less and leave more room for more variation in insurance design — though this obviously means it will be less valuable and helpful to some of the people now getting subsidies.
.. Where today, people newly covered by Obamacare’s Medicaid expansion (who tend to be childless adults with relatively higher incomes than the non-expansion population) are funded by the federal government on much better terms than the traditional Medicaid population (which tends to include more women with children and people with even lower incomes), the Senate bill would gradually equalize funding for the two groups, effectively shifting Medicaid’s focus back to the most vulnerable of its beneficiaries.
.. the Senate bill would provide an income and age-based subsidy that would allow these lowest-income individuals to afford at least modest insurance coverage in the individual market.
.. the Senate bill as written would probably mean that Medicaid would cost the federal government about 30 percent more ten years from now than it does today (as opposed to about 65 percent more under current law), and would cover something like the same number of people at that point as today (as opposed to 10 million more under current law)
.. once states got their bearings about just how much it would allow them to do, we could see some genuinely different approaches to health-insurance regulation among the different states — with blue and red models, rural and urban approaches, and more and less competitive systems.
.. alters a portion of a broader pre-existing statute. But it is very broad. In its scope and structure, this redesigned waiver would be unlike anything else in American federalism — which also means we don’t know how it would work. Those of us inclined to look favorably upon a bottom-up, experimental mindset in policy design will be inclined to think the best of the possibilities here.
.. it looks like this provision would render any insurer who offers an individual-market plan that covers abortion in a given state ineligible to benefit from the stability fund in that state. It seems to me, though I can’t say I’m sure, that this would effectively mean that no insurance plans in the individual market would cover abortion. It could easily even mean that California, which has a state law requiring individual-market plans to cover elective abortion, would have to repeal that law or else forgo access to the stability fund.
The House Should Slow Down and Fix the GOP Health-Care Bill
Many of the conservatives most engaged in the details of health care in recent years, meanwhile, thought its credit was not well designed to allow most people to obtain at least catastrophic coverage
.. Many of the conservatives most engaged in the details of health care in recent years, meanwhile, thought its credit was not well designed to allow most people to obtain at least catastrophic coverage.
.. The great bulk of the relative coverage loss that the agency projects is a function of three core assumptions. First, it assumes that well over 10 million Americans now buy coverage only because they don’t want to pay the individual-mandate penalty and simply wouldn’t buy any insurance absent a penalty. Second, it assumes that Medicaid spending growth will accelerate much faster than overall health spending in the coming years
.. The great bulk of the relative coverage loss that the agency projects is a function of three core assumptions.
- First, it assumes that well over 10 million Americans now buy coverage only because they don’t want to pay the individual-mandate penalty and simply wouldn’t buy any insurance absent a penalty.
- Second, it assumes that Medicaid spending growth will accelerate much faster than overall health spending in the coming years
- And third, it assumes that letting insurers have much more latitude to offer people different kinds of insurance products (including coverage with premiums equal to the new tax credit they could receive) would not result in significant numbers of new insurance products that could appeal to consumers.
.. Most conservative health-reform plans in recent years proposed to make an individual mandate unnecessary by using “continuous coverage” protections
.. a 30 percent surcharge on the premiums of people who have been without coverage for more than three months. This is certainly an inadequate spur to get covered, and indeed it would tend to discourage healthier people from getting insured.
.. it does not do enough to enable people with incomes just above Medicaid eligibility to purchase attractive coverage.
.. The House Republican proposal has clearly been designed with a very specific set of assumptions in mind about what can make it past the Byrd rule in the Senate, and these assumptions account for most of the bill’s peculiar features
.. They also account for much of the bill’s trouble both with Republican members of Congress and with the CBO.
.. a repeal of the law’s taxes, mandates, and subsidies that left in place its regulations would leave far more people uninsured than would a complete repeal that also eliminated the law’s insurance rules. This is because eliminating those regulations would let insurers offer more-varied products and give them a better chance of surviving in the individual market. The same is surely true regarding the House Republican bill: If it repealed more of Obamacare, it would help more people get covered.
.. the House Republican bill occupies an untenable middle space between two more-plausible approaches to conservative health-care reform.
.. On the one hand, House Republicans might conclude that it is not their job to solve procedural problems in the Senate and then proceed with a bill that aggressively rolled back Obamacare’s regulations and replaced them altogether. Such a bill would return nearly all insurance regulation to the states and subsidize catastrophic coverage (with continuous-coverage protection and a credit more generous at the bottom) in a way that enabled everyone in the individual market to afford at least that much.