Bobo is being a bit of a scold this morning. In “A Choice, Not a Whine” he snaps that opponents of Obama’s health care law should stop venting about John Roberts and instead provide a credible alternative. He then trots out a series of GOP talking points. In other words, typical Bobo. Mr. Nocera, in “Filling the Skills Gap,” says a high school diploma is no longer enough in today’s economy, so community colleges need to step up. Here’s Bobo:
Hostility toward the Supreme Court has risen sharply since Chief Justice John Roberts Jr. upheld the Obama health care law. People are apparently angry that the court didn’t rid them of a law they detest. But that’s silly. If Americans want to replace this thing, they should do it themselves.
The case against Obamacare is pretty straightforward. In the first place, the law centralizes power. Representative Tom Price, a Republican of Georgia, counted 159 new federal offices, boards and councils, though nonpartisan researchers have had trouble reaching an exact tally. In the first six months after passage alone, federal officials churned out an awesome 4,103 pages of regulations.
The law also creates the sort of complex structures that inevitably produce unintended consequences. The most commonly discussed perverse result is that millions of Americans will lose their current health insurance.
A report by the House Ways and Means Committee found that 71 of the Fortune 100 companies have an incentive to drop coverage. But nobody really knows what’s going to happen. A Congressional Budget Office study this year estimated that 20 million could lose coverage under the law or perhaps 3 million could gain employer coverage. Or the number could be inside or outside the range.
There are other possible perverse effects. According to a report from the Department of Health and Human Services, over the next 75 years Medicare payment rates for inpatient hospital services would steadily fall from around 67 percent of private insurance payment rates to an implausibly low 39 percent. Doctors would either flee the program in droves or Congress would override the law, exploding the costs.
Another report from the department suggests there could be 84 million Americans on Medicaid, an astounding burden on that already stretched system.
The law threatens to do all this without even fixing the underlying structures that make the American health care system so inefficient. It fails to fix the fee-for-service system that rewards people for the volume of services provided. It fails to fix the employer tax exemption that hides costs and encourages overspending.
Critics of the bill shouldn’t be hating on Chief Justice Roberts. If they can’t make this case to the voters, they really shouldn’t be in public life.
Moreover, there are alternatives. Despite what you’ve read, there is a coherent Republican plan. The best encapsulation of that approach is found in the National Affairs essay, “How to Replace Obamacare,” by James C. Capretta and Robert E. Moffit. (Mitt Romney has a similar plan, which he unveiled a little while ago and now keeps in a secret compartment in subsection C in the third basement of his 12-car garage).
Capretta and Moffit lay out the basic Republican principles: First, patients should have skin in the game. If they are going to request endless tests or elaborate procedures, they should bear a real share of the cost. Instead of relying on the current tax exemption that hides costs, the Republican plans would offer people a tax credit for use to purchase the insurance plan that suits their needs. The tax credit could phase out for the wealthy. Employees of small business who aren’t covered now would see an immediate benefit, which they could take from job to job.
Second, Americans should be strongly encouraged to buy continuous coverage over their adulthood. Then insurance companies would not be permitted to jack up their premiums if a member of their family develops a costly condition.
Third, the Republican approach would encourage experimentation in the states instead of restricting state flexibility.
Fourth, instead of locking Medicaid recipients into a substandard system, the Republicans would welcome them into the same private insurance health markets as their fellow citizens. This would give them greater access to care, while reducing the incentives that encourage them to remain eligible for the program.
Fifth, this approach would replace Medicare’s open-ended cost burden with a defined contribution structure. Beneficiaries could choose from a menu of approved plans. If they wanted a more expensive plan, they could pay for it on top of the fixed premium.
Finally, under this approach, any new spending would be offset with cuts so that health care costs do not continue to devour more and more of the federal budget. This could be done, for example, by gradually raising the retirement age.
Capretta and Moffit have more details. Their plan is flexible, decentralized and compelling.
Republicans say they trust the people. If that’s true, then they won’t waste another futile breath bashing the court for upholding Obamacare. They’ll explicitly tell the country how they would replace it. Democracy is a contest between alternatives, not a deus ex machina stroke from the lords in black robes.
Oh, by the way Bobo, I’ve spent most of my life dicking around with a “menu” of insurance “choices” offered by various employers, being shuttled from one set of “preferred providers” to another. It sucks in the high 90s. You can now keep your filthy predatory paws off my Medicare. Here’s Mr. Nocera:
A man named Gerald Chertavian came by my office not long ago, and, by the time he left, I was filled with renewed appreciation for the potential of community colleges to help stem the decline of the middle class. There are few more urgent tasks.
Chertavian is not the president of a community college or even a teacher at one. Rather, he runs a program, Year Up, which he founded, that makes it possible for poor high school graduates to land good jobs. It does so, in part, by imparting important soft skills that the upper-middle-class take for granted, like how to interact with colleagues in an office setting.
A second aspect of the program involves teaching marketable skills in such areas as computer support, say, or back-office work at financial firms. These are called middle-skill jobs; they require more than a high school education but less than a four-year baccalaureate degree. Thirty years ago, said Chertavian, middle-skill jobs didn’t exist. “There were jobs that required a college degree, and jobs that didn’t. Now,” he said, “up to a third of all jobs are middle-skill jobs.” Almost universally, companies complain that they can’t find enough workers to fill those jobs.
As a result, Chertavian has had no trouble rounding up corporations like General Electric and Bank of America to give internships to his charges; if all goes well — and it usually does — they wind up with a well-paying job. The entry-level pay can be as much as $40,000 a year.
The trouble with programs like Chertavian’s is that they are akin to pebbles being thrown in the ocean. He has identified a sweet spot in the economy — matching motivated, but disadvantaged, young people with a genuine economic need. But Year Up, which operates in nine cities, can absorb only 1,400 students a year. What about the millions of others who don’t have access to a program like that?
It was when I posed that question to Chertavian that he started talking about community colleges. He is a fierce believer in their transformative potential. All the students in Year Up are also required to be enrolled in a local community college, but, more recently, Chertavian has begun to affiliate more formally with community colleges. That would allow Year Up to reach many more students.
Most notably, it is about to begin operating at Miami Dade College, which has a staggering 174,000 students. Its president, Eduardo Padrón, says that 90 percent of its students are minorities, 40 percent live in poverty and 60 percent require remedial education. Many are enrolled in four-year baccalaureate programs; though it remains primarily a community college, in recent years, it has begun offering four-year degrees. But most are not. They are looking to earn a certificate or an associate degree and acquire a skill that will lead to a good job.
“Community colleges are the great American invention in terms of education,” Padrón said at a recent panel discussion I attended in Aspen, Colo. Their raison d’être has always been to help grease the wheels of social mobility. But, in their earlier incarnation, they were primarily seen as a passageway to a university degree. (They used to be called junior colleges, after all.) Now with the skills gap such a pressing problem — and a high school education so clearly inadequate for the modern economy — the task of teaching those skills is falling to community colleges. There really isn’t another institution as well positioned to play that role.
I wish I could say that state legislatures were pouring resources into community colleges, but, of course, I can’t. Many state governments have ravaged the budgets of their community college systems, just as they have for many state university systems. In Florida, said Padrón, community colleges have seen their state support drop by 21 percent in three years. “State support used to account for 75 percent of our budget,” he said. “Now it is only 45 percent.” As a result, tuition at Miami Dade is $3,000 a year — a lot of money for people of little means. Given what’s at stake, it would be hard to imagine anything more shortsighted than paring back support for community colleges.
Nor can it be said that all community colleges have stepped up to this new role. In some states, such as Virginia and North Carolina, community colleges have become deeply connected with employers in the state. In others, they remain the stepchildren of the educational system. Graduation rates are low. Overcrowding is common.
“Yes, there are many institutions that need to do a much better job adapting to and connecting with labor markets,” Chertavian wrote in a follow-up e-mail message to me. But he remains hopeful. “They are the mechanism that creates pathways to get young people into the economy,” he said.
Community colleges can be our salvation, if only we let them.