The most direct consequence of the presidential election is that, as GOP House Speaker John Boehner put it, "Obamacare is the law of the land."
The Affordable Care Act is complex. It was drafted by health-care wonks, and poll after poll indicate few voters understand it. That doesn't mean it's a good law, but it does mean that most voters relied heavily on the opinions expressed by their favorite politicians, all of whom had an incentive to either demonize or glorify "Obamacare."
Many voters who lean Democratic, therefore, were convinced that thousands of Americans would die on the street if President Barack Obama lost. Many who leaned Republican believed the law would crash the economy and create socialized medicine.
Neither extreme is accurate.
Despite the fact no Republicans voted for Obamacare, it is a remarkably bipartisan piece of legislation. Major portions of the law came directly from Obama challenger Mitt Romney and conservative icon Newt Gingrich. Many of the Democrats who voted for it in Congress were conservatives worried about keeping their seats. Until 2014, when it takes full effect, most voters will have little understanding of how its reforms will affect them.
The law leaves the private sector as the dominant force in U.S. health care. It increases competition through insurance exchanges. Those exchanges would be run by the states, except in states — such as Alabama — that prefer federal control to the political taint of acknowledging the law.
It also expands Medicaid, except in states — like Alabama — that prefer hundreds of thousands of working men and women to remain uninsured.
Gov. Robert Bentley is stuck in an odd loop. His political successes have come in significant part from bashing Obamacare. The people of Alabama largely took him at his word. Having fired up the troops, though, he must be subservient to those troops or risk a re-election mutiny.
The reasons Bentley gave last week in refusing to implement a state exchange — despite a recommendation by the commission he appointed that he implement it — and in rejecting the Medicaid expansion appeared entirely political. He has time to change both decisions.
The exchange would cost no state dollars, either in its creation or on an ongoing basis.
The Medicaid expansion would cost no state dollars for at least three years, and the state's obligation would cap out at 10 percent after that. So when Bentley says he is worried about costs to the state, he is referring to costs that may materialize after 2017. Obamacare contains numerous cost-containment provisions. Whether they will be effective is a matter of debate, but it is too early for Bentley to know what additional costs the state would incur once the federal government's 100 percent coverage of the expansion drops. And of critical importance, Alabama could backtrack on the expansion after three years, thus eliminating any risk of an undue burden on the state budget.
Faced with these facts, most conservatives resort to the argument that Alabama should not participate in a program that will increase the federal deficit. The Affordable Care Act, however, reduces the deficit.
An argument I have not heard Bentley make, but that is common among his constituents, is that poor people abuse welfare programs. Maybe there is truth to this for programs involving food stamps or cash payments, but the same logic does not hold for access to health care. Even people with excellent insurance — like me — tend to utilize it too little. There is no incentive to sit in a doctor's office beyond that of recovering from an ailment. There is no way to convert health care into cash. Sick people need health care, but they have no economic motivation to get more than they need.
Of the 33 developed nations — many of them as ardent in their appreciation of capitalism as ours — only the United States has resisted adopting universal health care. Most have systems in which the federal government exerts far more control than would be the case under the Affordable Care Act.
Bentley helped create an environment in which his political future depends on opposing the law. He may not believe the Affordable Care Act is the ideal solution, but he is enough of a realist to understand it's the only one on the table. Both as a doctor and as a man of compassion, he must understand the human misery that will continue for the 300,000 Alabamians who will be deprived of health care because of his decision to thumb his nose at Obamacare.
As a governor committed to economic development, he also understands the economic benefits to the state of an additional $6 billion of federal money, especially when invested in the state's struggling health care system. And he presumably understands that federal money currently given to Alabama hospitals to help them care for the poor will end — to help fund the Medicaid expansion — creating a direct loss to the hospitals if the expansion does not take place.
Florida Republican Gov. Rick Scott, an aggressive opponent of the Affordable Care Act, is struggling to decide whether he will cooperate with what is now the law of the land. His comment: "I'm responsible for the families of Florida."
Bentley is responsible for the families of Alabama. He can best meet that responsibility by ignoring the political environment he helped create and doing what is right.
Contact Eric Fleischauer at email@example.com.
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