States Saying No to Health Care Marketplaces is Good News

Feb 26, 2013Richard Kirsch

ObamaCare has a better chance at success if it's taken out of the hands of Republican governors who want to see it fail.

The headlines – “Many States Say 'No' to Health Insurance Exchanges,” to take one example – make it seem like bad news. But it’s not. It is good news that half the states are refusing to have anything to do with the new health insurance marketplaces being set up under the Affordable Care Act.

ObamaCare has a better chance at success if it's taken out of the hands of Republican governors who want to see it fail.

The headlines – “Many States Say 'No' to Health Insurance Exchanges,” to take one example – make it seem like bad news. But it’s not. It is good news that half the states are refusing to have anything to do with the new health insurance marketplaces being set up under the Affordable Care Act.

One of the biggest differences between the good version of ObamaCare passed by the House and the mediocre Senate version that became law was the question of whether the federal government or states would run the new health insurance marketplaces (called “exchanges” in the law). But resistance by Republican governors is leading to implementation of the law in a way that is much closer to the vision in the House bill.

The new health marketplaces are the centerpiece of ObamaCare, the mechanisms through which people who don’t get health coverage at work but make too much for Medicaid will be able to purchase subsidized health coverage, even if they have a pre-existing condition. The marketplaces, which are projected to cover 12 million people in 2012 and 29 million by 2021, will also offer more affordable insurance plans to small businesses.

The House legislation would have had the federal government run the marketplaces while allowing states the option of taking over if they could demonstrate the ability to do at least as good a job. Consumer advocates hoped that the result would be a good national marketplace, with some exemplary states demonstrating how to do an even better job at providing quality coverage and good access while controlling costs.

But the Senate legislation, which became law, gave the primary responsibility to each state to set up a marketplace, with the federal government as backup. Advocates were not pleased for two reasons. The first was a concern that states would do a very minimal job of protecting consumers. The second worry was that states would fumble the complicated task of getting the exchanges up and running by October 1, 2013, when they are open for enrollment.

In reality, the reluctance of so many Republican governors to cooperate with ObamaCare has led to the creation of a system that looks more like the House bill. The federal government will run the exchanges in 25 states and will have primary responsibility, in partnership with states, in seven more.

The last thing consumers needed was for governors who want the ACA to fail – like Florida’s Rick Scott and Texas’s Rick Perry – to be in charge of the law’s implementation. We can be sure that governors in these states would do the minimum amount under the law to sign people up or to protect consumers from high-priced, poor-quality health insurance plans.

On the other hand, some of the states that have decided to set up their own marketplaces are doing what the authors of the House law hoped: being models. Massachusetts, which has been running a marketplace since 2007, is the trailblazer. The state did an excellent job promoting health care coverage and making it easy to sign up, either online or in person. There are strict conflict-of-interest protections for the individuals who govern the marketplace. And they have only contracted with health insurance providers, including community providers, that offer quality coverage at a reasonable cost. As a result, premium inflation has been low.

Several states look like they will follow the Massachusetts example, including California, Connecticut, the District of Columbia, Oregon, Rhode Island, and Vermont (which is moving toward a single-payer plan in 2017). If these states prove successful in demonstrating that acting on behalf of individuals and small businesses results in better access at lower costs, the example is likely to be followed by other states and the federal government.

The open question is how good a job the Federal Department of Health and Human Services will do running the marketplaces in 32 states. This year, HHS is setting its sights on the essentials. The top priority – no small challenge – is getting up and running by October 1st, when people and small businesses can start enrolling. Setting up online systems that account for the different plans and the varying Medicaid and Child Health Insurance eligibility rules in each state is daunting. Enrollment will only be available online, and plans will be easy to compare. However, there will be contracts with state-based groups to assist with outreach and enrollment. The feds say they will pay at least some attention to assuring that community health centers are included as providers by some insurers.

For now, HHS is not implementing key measures to assure that quality health insurance is provided at the best possible cost. It has decided to wait four years until all health insurance plans must be fully accredited by quality assurance bodies. More significantly, it will not initially use its biggest tool, restricting access to the marketplaces to health insurance plans that meet quality standards at a reasonable cost. Most people in the health exchanges will have their costs capped at a percentage of their income, with the government picking up the difference. So limiting insurance plans to those that provide good value will be essential to keeping the system affordable to the government and resisting pressure to increase the cost to consumers.

This October, three and a half years after the ACA was passed, consumers will start enrolling in the new marketplaces. At that point, the debate about ObamaCare will shift from theory to practice. It is vitally important that people learn about the new marketplaces and can readily comparison shop and qualify for income-based subsidies for coverage. There will be huge headaches in the process. But there will be a lot fewer problems than if every state in the union was doing this on its own. It’s good to have one instance where opposition to ObamaCare from the right is all for the best. 

Richard Kirsch is a Senior Fellow at the Roosevelt Institute, a Senior Adviser to USAction, and the author of Fighting for Our Health. He was National Campaign Manager of Health Care for America Now during the legislative battle to pass reform.

 

Rick Perry image via Christopher Halloran / Shutterstock.com.

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Emergency Contraception Use Spreads, but Many Women Are Still Left Out

Feb 26, 2013Ellen CheslerAndrea Flynn

New evidence shows more young women are using emergency contraception but we still have work to do to reduce all barriers.

New evidence shows more young women are using emergency contraception but we still have work to do to reduce all barriers.

A federal study released recently shows that use of emergency contraception (EC) in the United States, known colloquially as the “morning after” pill, has more than doubled in the past decade. This is good news. It demonstrates the critical and expanding role the method may now be playing in enabling women, particularly young women, to prevent unplanned pregnancies. But there are still serious hurdles women face in accessing this method of birth control. While access has expanded, there is still work to be done.

The study, conducted by the Centers for Disease Control and the National Center for Health Statistics, strengthens the case for promoting EC widely and making it more readily available. Based on interviews with more than 12,000 women from 2006-2010, the research finds that EC use among all sexually experienced women between the ages of 15-44 has increased to 11 percent (up from a baseline of 4.2 percent). That number is even higher among women 20-24, one of the highest risk groups for unplanned pregnancy. Nearly a quarter of this cohort now reports having used EC.

This is no coincidence. In 2006, nearly a decade after EC first entered the market under the trade name Plan B and after years of stalling and political maneuvering by the Food and Drug Administration (FDA), the agency finally ruled that the product can be provided without prescription to women over the age of 18. A year later, a federal judge ordered the FDA to make it available to women over the age of 17. An important provision of the Obama administration’s Affordable Care Act (ACA) also now promises to cover the cost of all methods of contraception, including this one.

The government study confirms what we already know: accidents happen. Half the participants report having used EC out of fear that their initial birth control method had failed; the other half used it because they had unprotected sex. This reminds us that even women who have a “plan A” need a “Plan B,” or, as the product is now also marketed, a “Next Choice.” Nearly one-third of all U.S. women using contraception rely on the pill, and approximately 16 percent use condoms – both effective methods when employed perfectly, but also ones prone to human error. Condoms break, and sometimes women forget to take a daily low-dose pill. And then there are still the many women who, because of lack of access, cost, forgetfulness, or spontaneity, still don’t consistently use birth control and need protection after the fact.

One of the most common arguments against EC is that it is really just an early abortion method masked as contraception. This simply has no basis in science, as most recently explained by the International Federation of Gynecology and Obstetrics. Unlike medication abortion, which terminates a pregnancy in its earliest stages, EC actually prevents a pregnancy from occurring.

The next most popular and equally erroneous claim is that increased access to EC – and, for that matter, any program or product that provides access to abortion, contraception, or sexuality education – will promote risky sexual behavior. Studies from diverse countries over many years tell us this is not the case. But new research coming out of New York City now confirms that access to EC right here at home does not encourage young people to become more sexually active. In fact, it does just the opposite. The NYC Department of Health recently reported a 12-point drop over 10 years, from 51 to 39 percent, in the proportion of public high school students who are sexually active. Over the past few years, the proportion of sexually active students using contraception, including Plan B, increased from 17 to nearly 27 percent. Both trends coincided with an expansion of school-based health centers that provide free contraception (including EC), counseling, and sexuality education.

So now we have homegrown data to show that when young people have access to sexual health information, no or low-cost products and services, they make better and safer decisions about their reproductive and sexual lives.

But while the federal data illustrates an overall increase in EC use, it also reveals an educational and economic divide among women who use it, suggesting the need for better information and access for low-income women. The CDC study finds that EC use is highest among college-educated women (12 percent), compared to women who have only completed high school or received a GED (7 percent). A 2011 study conducted by researchers at the Boston University School of Public Health also found that while a majority of pharmacies in low-income neighborhoods do have EC available, they often provide incorrect information about eligibility.

Add this to a number of other potential barriers, and it is clear why EC use isn’t higher.

The drug is not actually sold over the counter, where it would be most accessible, but rather behind the counter, where a pharmacist must retrieve it. (Still, this makes it more widely available in the 72-hour window after unprotected intercourse when it works most effectively.) Nine states around the country have a “conscience clause” on the books that permits pharmacists to deny filling a prescription on religious or moral grounds. Only 17 states and the District of Columbia explicitly require hospital emergency rooms to provide EC and related services to sexual assault victims.

The cost of EC is prohibitive for many potential clients. Plan B and Next Choice, the two most popular products on the market, range in price from $35 to $60 at a pharmacy and from $10 to $70 at Planned Parenthood and other public health clinics, which offer an income-based sliding fee scale and often include counseling and other services.

Even at these high prices, the limited market for the product may not provide private drug companies any incentive to advertise it beyond women’s magazines or other niche marketing sites. This means that young women just becoming sexually active, and all women who do not regularly visit a clinic or a private physician, may never learn about it. Age restrictions requiring a photo ID and concerns about confidentiality may also be intimidating and restrict use.

There are also a number of potential hurdles to EC provision under the Affordable Care Act. Will women be able to use their private insurance or Medicaid benefits to purchase it at a drug store? Or will they need to visit a Planned Parenthood or community clinic? What about the many states that are not planning to participate in the Medicaid expansion? How will low-income women in those states receive information about and access to EC and, for that matter, regular methods of contraception?

In recent years, Planned Parenthood has put forward an effective reproductive health information campaign using online and cell phone platforms. Millions of women, and especially young people, are now texting or visiting its website each month to learn about and gain access to EC, along with other important sexual health information.

The Obama health care plan needs to imitate and vastly expand this marketing approach if it is to be effective. At long last, the Affordable Care Act promises to provide a national policy that prioritizes women’s health and primary, preventive care. But we must seek greater clarity about its implementation. Our next challenge will be to buttress the ACA with an inventive, far-reaching public information campaign so a broad and diverse population can understand and access its many benefits. How about calling this campaign “Morning After in America"? For those Americans old enough to remember Ronald Reagan, this surely has a familiar ring!

Ellen Chesler is a Senior Fellow at the Roosevelt Institute and author of Woman of Valor: Margaret Sanger and the Birth Control Movement in America. Andrea Flynn is a Fellow at the Roosevelt Institute. She researches and writes about access to reproductive health care in the United States. 

 

Contraception image via Shutterstock.com.

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The Real State of the Union Requires a Stronger Government

Feb 15, 2013David B. Woolner

Instead of downplaying the role of government, we should recommit to a "spirit of charity."

We of the Republic sensed the truth that democratic government has innate capacity to protect its people against disasters once considered inevitable, to solve problems once considered unsolvable…

In this we Americans were discovering no wholly new truth; we were writing a new chapter in our book of self-government . –Franklin D. Roosevelt, 1937

Instead of downplaying the role of government, we should recommit to a "spirit of charity."

We of the Republic sensed the truth that democratic government has innate capacity to protect its people against disasters once considered inevitable, to solve problems once considered unsolvable…

In this we Americans were discovering no wholly new truth; we were writing a new chapter in our book of self-government . –Franklin D. Roosevelt, 1937

In his State of the Union address, President Obama challenged the Congress and the American people to join him in a common effort to make the United States a better nation; to recognize that while we “may do different jobs, and wear different uniforms” we are all “citizens” imbued with the rights and responsibility “to be the authors of the next great chapter in our American story.”

Certainly, the president’s call for “investments” in setting up universal preschool, increasing access to higher education, promoting research and development, fixing our broken infrastructure, and establishing a higher minimum wage so that in “the wealthiest nation on earth, no one who works full-time should have to live in poverty,” is a welcome development. So too is the president’s acknowledgment that there are still communities in this country where, thanks to inescapable pockets of rural and urban poverty, young adults find it virtually impossible to find their first job. “America,” he insisted, shouldnot [be] a place where chance of birth or circumstance should decide our destiny.”

And yet, if we examine the state of our union honestly, it not only becomes apparent that we are indeed a society where “chance of birth or circumstance” decides our destiny, but also a society that has fallen far behind the rest of the world in education, health care, infrastructure, and a host of other indicators that determine the overall quality of life.

In study after study, for example, Americans are found to be far less economically mobile than their counterparts in Canada and Europe. In education, the U.S. now ranks 17th in the developed world overall, while we are ranked 25th in math, 17th in science, and 14th in reading, well behind our Asian and European counterparts. For decades the U.S, was ranked number 1 in college graduation, but we now stand at number 12, and even more shocking, we are now ranked 79th in primary school enrollment. This is no way to sustain or build a competitive edge in a global economy.

Other statistics tell a similar tale. How many Americans, for example, are aware that out of the 35 most economically advanced countries in the world, the U.S. now holds the dubious distinction of ranking 34th in terms of child poverty, second only to Romania? In infant mortality, the U.S. ranks 48th. As for overall health and life expectancy, a recent report by the Institute of Medicine and the National Research Council found that among the 17 advanced nations it surveyed, the U.S.—which in the 1950s was ranked at the top for life expectancy and disease—has declined steadily since the 1980s. Today, “U.S. men rank last in life expectancy among the 17 countries in the study and US women rank second to last.” In infrastructure, the World Economic Forum recently ranked the U.S. 25th in the world, behind virtually all other advanced industrialized nations and even some in the developing world.

Still, there are some categories where the United States ranks number one: we have the highest incarceration rate in the world—far higher than countries like Russia, China, or Iran. We have the highest obesity rate in the world and we use more energy per capita than any other nation. And while the U.S. does not possess the highest homicide rate in the world—that distinction goes to Honduras—the rate of death from firearms in the U.S. is nearly 20 times higher than it is among our economic counterparts. And on a city-by-city basis, we would find that if New Orleans were a country, for example, its homicide rate would rank number 2 in the world.

Eighty years ago, when the United States found itself in an even more precarious state than it does today, Franklin Roosevelt used the occasion of his first inaugural address to say to the American people that “this is preeminently the time to speak the truth, the whole truth, frankly and boldly,” to avoid the temptation “to shrink from honestly facing conditions in our country today.” The president then went on to implore the American people to reject the fear and apprehension that had paralyzed the nation by reminding them that “in every dark hour of our national life, a leadership of frankness and of vigor has met with that understanding and support of the people” which is essential to overcoming the challenges we face.

Four years later, in the first State of the Union address of his second term, President Roosevelt observed that “the deeper purpose of democratic government is to assist as many of its citizens as possible, especially those who need it most, to improve their conditions of life…” But, he went on, even with the “present recovery,” the United States was “far from the goal of that deeper purpose, for there were still “far-reaching problems… for which democracy must find solutions if it is to consider itself successful.”

President Obama certainly echoed these sentiments when he spoke about the meaning of citizenship and “the enduring idea that this country only works when we accept certain obligations to one another and to future generations; that our rights are wrapped up in the rights of others.” But the president said little about the role of government in ensuring that these obligations are met, and he qualified his remarks by opening his speech with his oft-repeated maxim that the American people do not expect government “to solve every problem.”

FDR took a different tack. For him government was the instrument of the common people, and as such its primary responsibility was not to serve as an arbiter between the demands of the rich and the needs of the poor, but rather as the vehicle through which the hopes and aspirations of all Americans could be met. In this he argued that:

The defeats and victories of these years have given to us as a people a new understanding of our government and of ourselves…It has been brought home to us that the only effective guide for the safety of this most worldly of worlds, the greatest guide of all, is moral principle.

We do not see faith, hope, and charity as unattainable ideals, but we use them as stout supports of a nation fighting the fight for freedom in a modern civilization…

We seek not merely to make government a mechanical implement, but to give it the vibrant personal character that is the very embodiment of human charity.

We are poor indeed if this nation cannot afford to lift from every recess of American life the dread fear of the unemployed that they are not needed in the world. We cannot afford to accumulate a deficit in the books of human fortitude.

In the place of the palace of privilege we seek to build a temple out of faith and hope and charity.

To bring about a government guided by the “spirit of charity,” FDR initiated the most far-reaching social and economic reforms in our nation’s history; reforms designed to provide the average American with a measure of economic security; reforms that reduced the vast, unjust, and unsustainable economic inequality that had brought the country to ruin just a few short years before.

If we are going to “honestly” face “conditions in our country today,” then we need to recognize that the steady abandonment of the principles of governance put in place by Franklin Roosevelt in the past three decades have done enormous harm to the state of the union. In light of this, rather than repeat the conservative mantra that government cannot solve every problem, perhaps President Obama should follow the example of President Roosevelt by reminding the Congress and the American people that even though

Governments can err, [and] presidents do make mistakes… the immortal Dante tells us that Divine justice weighs the sins of the cold-blooded and the sins of the warm-hearted on different scales.

Better the occasional faults of a government that lives in a spirit of charity than the consistent omissions of a government frozen in the ice of its own indifference.

David Woolner is a Senior Fellow and Hyde Park Resident Historian for the Roosevelt Institute. He is currently writing a book entitled Cordell Hull, Anthony Eden and the Search for Anglo-American Cooperation, 1933-1938.

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What Did the State of the Union Say to Women?

Feb 14, 2013Ellen CheslerAndrea Flynn

The president didn't just lay out specific policies that will benefit women. He also shifted the theory of how government can help them.

The State of the Union address is inherently a political exercise, intended to chart a course for governing but also to let important constituencies know that they are heard and valued. On Tuesday night, President Obama seemed intent on sounding down-to-earth, sensible, unthreatening, and easy to understand. He presented a long list of concrete proposals as if there couldn’t be any disagreement over their merits.

The president didn't just lay out specific policies that will benefit women. He also shifted the theory of how government can help them.

The State of the Union address is inherently a political exercise, intended to chart a course for governing but also to let important constituencies know that they are heard and valued. On Tuesday night, President Obama seemed intent on sounding down-to-earth, sensible, unthreatening, and easy to understand. He presented a long list of concrete proposals as if there couldn’t be any disagreement over their merits.

For women, a critical voting bloc who helped deliver his second term, the president checked off many important boxes. He spoke about ending violence against women, guaranteeing them equal pay, preventing teen pregnancy, providing working families with more daycare and early child education, and promoting military women in combat roles. He also acknowledged that women around the world are drivers of prosperity and must be empowered if we hope to reduce global poverty and secure emerging democracies.

Hearing this litany of familiar issues was reassuring, but the overall theme of the speech provided an even more important takeaway. Without much fanfare, the president put forward a reshaped agenda for government programs that are, as he put it, not “bigger” but “smarter.” This is vital for women because it would have the government target policies and marshal resources for women and families, which, in turn, prevent larger and costlier social and economic problems. It’s a welcome departure from forgetting about women and children and waiting around to address the unfortunate consequences after the fact.

No grand principles were enunciated. But the president craftily put forward a theory of change that emphasizes strategic and comprehensive investments and interventions to establish a floor of well being for at-risk women and families.

  • He called on the House of Representatives to follow the Senate’s lead and reauthorize the Violence Against Women Act, not just as a moral imperative but because studies since its passage demonstrate the effectiveness of the social services and criminal justice reforms this pioneering legislation funds. Over two decades, rates of intimate partner violence and homicides have decreased dramatically, as the White House recently reported.
  • He called for expanding mandatory and free early childhood education – currently available to only three in ten American children – not just because it’s the right thing to do for hard-pressed parents, but because the data shows that it also boosts graduation rates, decreases teen pregnancy, and even correlates with palpable reductions in violent crime in communities across the country.
  • He promised to fight to increase the minimum wage and pass the Paycheck Fairness Act. This would close a real gender earnings gap. It would also benefit the nearly two-thirds of all minimum wage workers who are female, many of them single heads of households who can’t possibly lift their families out of poverty without this critical and long overdue intervention. Small businesses have long opposed a raise, despite studies that demonstrate a return to employers through increased productivity.
  • He mentioned the Affordable Care Act only in passing, but it too provides many additional preventive policies, which, as he noted, are already improving services while driving down health care costs overall. For example, the ACA has already brought comprehensive, affordable family planning and reproductive health care to more than 1 million women. By 2016, it could extend those services to as many as 13 million additional uninsured women if the many state challenges to contraceptive coverage and the Medicaid expansion do not undermine its potential reach and impact. And here again, as we have written previously, data demonstrates incontrovertibly that these services will dramatically reduce rates of unintended pregnancy and abortion.
  • While the focus of the president’s speech was primarily domestic, he also mentioned America’s responsibilities in the world and obliquely referenced the signature efforts of his administration to mainstream gender considerations into our diplomatic, defense, and development policies. Under the president and Secretary of State Hillary Clinton, the United States has joined 30 other countries in adopting a National Action Plan on Women, Peace, and Security, facilitated by the United Nations, which applies gender considerations and disaggregates spending across all agencies to require focused investment to improve the status of women. The government recognizes that this is not just the right thing to do, but also the smarter course if our aim is to meet the security and development challenges of our foreign policy. This shift in thinking lies behind the decision to promote military women to combat rank, for example, because in conflicts that involve civilian populations, as in Afghanistan and Iraq, women officers on the frontlines have played critical roles in connecting with local populations. And local women empowered by the U.S. presence have in turn become important agents in post-conflict resolution and peace processes and in relief and reconstruction efforts.

The president’s State of the Union provided a blueprint for a strong, positive government obligation to secure the wellbeing of women and families at home and abroad. Not a lot of detail was offered, nor was there any fancy philosophical framework for what would represent a palpable shift in U.S. priorities and our traditional ways of governing. He spoke as if this was all pretty much just common sense – the better part of wisdom.

But certainly if Senator Marco Rubio’s response is any indication, the president’s intentions, however masked in straightforward, anodyne rhetoric, face innumerable obstacles to their realization. That should not, however, stop us from applauding and getting behind the potential for meaningful policy change.

Ellen Chesler and Andrea Flynn are Fellows at the Roosevelt Institute.

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The Progressive Economic Narrative in Obama's State of the Union

Feb 13, 2013Richard Kirsch

President Obama has begun telling the right story about the economy. Now we need to make sure that story spreads.

President Obama has begun telling the right story about the economy. Now we need to make sure that story spreads.

Two years ago, frustrated by a conservative resurgence in the 2010 election, a group of progressive activists, economists, communicators, and pollsters came together to write a compelling story about our view of the economy (as Mike Lux relates). Our goal was to write a story that people could easily understand, based on our beliefs about how to create an economy that delivered broadly shared prosperity -- a story that could stand up against the right’s familiar recipe of free markets, limited government, and rugged individualism. The core of the story we developed in our progressive economic narrative (PEN) was: “The middle class is the engine of our economy. We build a large, prosperous middle class by decisions we make together.”

So it was a milestone in our work to hear President Obama tell our story and use our language in his State of the Union address. The key line, delivered at the top of the speech and quoted in almost every news story, was “It is our generation’s task, then, to reignite the true engine of America’s economic growth: a rising, thriving middle class.”

Taking another lesson from PEN, the president prefaced that quote with an explanation of what the economic problem is, focusing on how working families and the middle class have been crushed. In PEN we say, “American families are working harder and getting paid less, falling behind our parents' generation. Too many Americans can’t find good jobs and too many jobs don’t pay enough to support a family. Big corporations have cut our wages and benefits and shipped our jobs overseas.” Here’s the president’s version:

But – we gather here knowing that there are millions of Americans whose hard work and dedication have not been rewarded. Our economy is adding jobs, but too many people still can’t find full-time employment. Corporate profits have skyrocketed to all-time highs, but for more than a decade, wages and incomes have barely budged. It is our generation’s task, then, to reignite the true engine of Americas economic growth: a rising, thriving middle class.

When it came to describing how we build this middle-class engine, the president again used the same ideas frame laid out in PEN: “We build a large and prosperous middle class through the decisions we make together; investing in our people, expanding opportunity and security, paving the way for business to innovate, and to do business in ways that create prosperity and economic security for Americans.” The president’s agenda was based on these same concepts:

  • Invest in people through education (starting at Pre-K), skills we need for today’s jobs, affordable health care, and a secure retirement.
  • Pave the way for businesses through research, infrastructure, and green energy.
  • Do business in ways that create prosperity, with a higher minimum wage and pay equity for women.

The president’s story contrasted sharply with Marco Rubio’s. Rubio also paid homage to the middle class, but he told the conservative tale:

This opportunity – to make it to the middle class or beyond no matter where you start out in life – it isn’t bestowed on us from Washington. It comes from a vibrant free economy where people can risk their own money to open a business. And when they succeed, they hire more people, who in turn invest or spend the money they make, helping others start a business and create jobs. Presidents in both parties – from John F. Kennedy to Ronald Reagan – have known that our free enterprise economy is the source of our middle class prosperity.

So the fight is joined. For too long, progressives have not taken on the conservative story with our own narrative. As a result, even when people agree with us on specific issues, they still hold fast to the right’s definition of how to move the economy forward. We have, with the simple tale told by the president and in the progressive economic narrative, a very different story, an economy driven by working families and the middle class, which we create by decisions we make together, with our government as the catalyst.

Our next task is to tell this same story over and over again in all of our communications. Repetition is key. People need to hear the story whenever we communicate on an economic issue. We give examples of how do to that on job quality, job creation, the federal fiscal mess, and health care at progressivenarrative.org.

President Obama left out one part of the progressive economic narrative in his speech. As we say in PEN, “Our political system has been captured by the rich and powerful and corrupted by big money in politics. The issue is not the size of the government, it’s who the government works for – powerful corporations and the richest few, or all of us. We have to take our democracy back to ensure that our economy will work for all of us. ”

That’s a story that politicians are reluctant to tell. As always, we need to lead and the leaders will follow. It is up to us to build an America and economy that works for all us. Clearly describing our vision of how to do that is a crucial element of building power that progressives overlooked for too long. We’re much closer when the president tells that story to the nation. It’s up to us to keep telling it every day.

Richard Kirsch is a Senior Fellow at the Roosevelt Institute, a Senior Adviser to USAction, and the author of Fighting for Our Health. He was National Campaign Manager of Health Care for America Now during the legislative battle to pass reform.

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Memo to Lawmakers: Young Americans Demand More Health Care, Not Less

Feb 13, 2013Rahul Rekhi

President Obama's SOTU mentioned Medicare, but he still fails to realize that young people are ready for even greater investment in health care.

President Obama's SOTU mentioned Medicare, but he still fails to realize that young people are ready for even greater investment in health care.

Last night, President Obama delivered a State of the Union address that outlined an ambitious second term agenda while touting a steadily recovering economy and asserting the need to strike a budget deal that preserves the generational promise of Medicare. What he did not mention, however, is an underlying but oft-neglected truth: that our national health care debate still neglects the needs, perspectives, and interests of young adults. The State of the Union may be stronger, but for young Americans around the country, its health requires a new prescription. This is perhaps most critical in two key but distinct areas: innovation and mental illness.

Consider, firstly, that the health reform debate—subsumed into the longstanding clashes on the federal debt and deficit—has lately centered on cost cutting. Thus far, such discourse has largely been framed as benefiting young Americans, those who, the argument goes, will bear the brunt of the nation's debt burden in the absence of immediate cuts to the federal healthcare budget. However, from a young person’s perspective, there exists compelling evidence for a converse narrative: public health care as an incubator for innovation. The safety net that health care provides actually emboldens young people to take risks, to try creating the next Facebook or Google, rather than play it safe for fear of being denied care in later years. 

Evidence of the critical role that public health care can play in entrepreneurship and innovation is plentiful in the research literature. For instance, a recent RAND Corporation study observed the prevalence of so-called "entrepreneurship lock": a phenomenon in which prohibitively high costs of obtaining health insurance as individuals preclude workers from leaving large firms that can offer subsidized premiums to strike out on their own. But we can also look across the Atlantic to see the catalytic properties of such social insurance—and the costs of not providing it—in action. For example, Sweden, a nation that possesses a social safety net among the world’s most robust, ranked 2nd globally on the INSEAD’s Global Innovation Index. The US, with comparatively meager public insurance, came in at a distant 10th. Such nations as Norway, Finland, Denmark, and Switzerland–hardly bastions of Randian self-sufficiency—also handily outstripped our own ranking on this measure.

This is not to say that public health care is the only factor that will determine the fates of Googles to come. But this data should prompt us to reformulate our rhetoric around programs like Medicare and Medicaid: not as hammocks, but springboards. We should not be focused on heavy-handed cost-shifting measures that merely limit the scope of coverage, but instead how to thoughtfully modernize the fundamental societal value that these programs provide. It is precisely this values-based approach to national health care financing that young Americans value most greatly, as attested to by thousands of students in the Roosevelt Institute | Campus Network’s recently published Government By and For Millennial America.

Arguably the most significant example of this false dichotomy between cost and value is mental health care. Much has been made of our healthcare system’s dismal performance on health indicators, but in no field does this ring truer than in psychiatric care. Yet what’s often overlooked is that mental healthcare is, above all, a youth problem, afflicting no demographic more than my fellow young Americans—my classmates, colleagues, and friends. Millennials, as a demographic, report rates of depression well above the baseline: almost 9 percent of 20-somethings in America are thought to have developed major depression, panic disorder, or anxiety. The shocking nature of this statistic is only amplified by considering that a full 75 percent of diagnosable, life-long mental health illnesses develop by age 24. Yet an estimated 75-80 percent percent of youth in need of mental health services do not receive any care.

But potential solutions abound, even for such a complex problem. If states are the laboratories of our democracy, mental health has proven no exception. Even while the U.S. lags nationally on mental health—rated a ‘D’ by the National Alliance on Mental Illness—states like Connecticut, Massachusetts, and Maryland lead the pack in developing thoughtful, innovative proposals to improve the quality and coverage of care. Moreover, a recent study out of UCLA in California demonstrates that sound mental healthcare can actually be a cost-saving measure.

Ultimately, progress on both of these fronts depends on whether our political leaders choose to prioritize young Americans across the nation. The health of an entire generation hangs in the balance.

Rahul Rekhi is a student at Rice University and the Senior Fellow in Health Care Policy for the Roosevelt Institute | Campus Network.

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The Battle Over Women's Health is a Fight for Human Rights

Dec 5, 2012Andrea Flynn

The election is over, but the work of expanding and improving women's access to quality health care is just beginning.

The election is over, but the work of expanding and improving women's access to quality health care is just beginning.

Last month, the United Nations declared access to family planning to be a universal human right that all member countries should respect, protect, and fulfill—a decidedly non-controversial concept for most of the developed world, and indeed not a novel concept for the UN or its members. That is, of course, with the exception of the United States, where human rights are mostly regarded as instruments for other countries to adopt and implement while considered quite unnecessary for our own advancement and wellbeing. So far are we from adopting a human rights framework at home that it’s hard to imagine what would happen if U.S. policymakers approached access to health care – and women’s health in particular – as a right akin to free speech, bearing arms, or practicing our religion. However, given our domestic women’s health crises, we could certainly benefit from adopting some outside perspectives on the right to health care.

Women’s health issues were front and center in the 2012 presidential campaign, garnering far more mainstream attention than in previous elections. From serious discussion in the primary and general election debates to thoroughly considered policy positions to uncensored public remarks, hot-button women’s health issues—rape, abortion, contraception—created a gender gap in the electorate to which many attribute President Obama’s victory. As we look toward the commencement of Obama’s second term, it's clear that the president has numerous monumental challenges before him. But we must not let the protection of women’s health and rights be compromised by other priorities such as the fiscal cliff, the federal budget, or foreign policy crises.

Obama’s victory was a win for women in the short term because it averted the immediate decimation of women’s health funding and infrastructure promised by Romney and his Republican counterparts across the country. But the country needs a long-term win: one that will improve the lives of American women and girls for generations to come. Such a win will require the president’s unwavering determination to improve women’s access to health services and their health outcomes throughout the course of his second term. And it is the job of women and the people who love them to provide a constant reminder that he must deliver on his promises.

Our government should ensure that all women have access to affordable, quality health care not only because it is morally the right thing to do, but because it is the smart and necessary thing to do to strengthen the entire country. Critical indicators such as maternal mortality, teen pregnancy, and unintended pregnancy illustrate the high cost of treating women’s health care as a privilege instead of a right. The United States trails 49 other nations in a ranking of maternal deaths worldwide and has a teen pregnancy rate higher than almost all other industrialized countries. Moreover, nearly half of all pregnancies in the United States are unintended. The data below illustrate how the health circumstances of women of color and low-income women have truly reached crisis proportions and demand immediate action.

(Sources: 1. National Campaign to Prevent Teen and Unplanned Pregnancy, 2. Centers for Disease Control and Prevention, 3. Guttmacher Institute, 4. Ibid, 5. Amnesty International, 6. Ibid, 7. New York City Maternal Mortality Review Project Team)

These inequities in women’s health in the United States are shameful, are a violation of human rights, and are, of course, directly related to the quality and availability of family planning and reproductive health care. Obamacare is certainly a historic step in the right direction. It has already extended contraceptive coverage (including highly effective methods such as the IUD, hormonal implants, and injections) to more than 1 million young women, and by 2016 it will cover nearly 13 million more. It also mandates the inclusion of other critical services: one annual “well woman” visit to a primary care physician, access to emergency contraception (also known as the morning-after pill), HPV testing, screenings for STDs, screenings for gestational diabetes, and coverage for maternal health care, including breast-feeding support.

Despite the immediate improvements to women’s health and the long-term cost savings associated with expanded coverage, Obamacare faces a steep uphill battle. Twenty-seven states have filed suit against the president’s plan, challenging its constitutionality. Additionally, over the last year a number of states have attempted to defund Planned Parenthood and other facilities that provide information about, referrals for, or counseling on abortion (even though none of these providers actually perform abortions), threatening to dismantle an irreplaceable infrastructure that has provided millions of women across the country with critical health services.

So far none of these states have succeeded in their lawsuits, but new challenges pop up every day. In Texas alone, more than 50 women’s health providers have closed over the past year as a result of Governor Rick Perry’s decision to slash the state family planning budget by two-thirds and his promise to eliminate Planned Parenthood and other clinics from the state’s Women’s Health Program. Numerous court battles are underway, but regardless of their outcome, the governor has successfully chipped away at a system of care upon which thousands of women – particularly young women, poor women, immigrant women, and women of color – have relied for decades. This system cannot be easily rebuilt.  As anti-choice and anti-family planning lawmakers across the country continue to face resistance from the courts, they will likely look to Texas for strategies of how to successfully defund our nation’s most effective, far-reaching women’s health care providers. Even if Obamacare succeeds in continuing the expansion of Medicaid and private insurance coverage, its impact will be diluted if women have fewer places to receive comprehensive, quality care.

The United States cannot afford these inequities. The National Campaign to Prevent Teen and Unplanned Pregnancy reports that nearly three in ten girls become pregnant in their teenage years and that teen childbearing now costs U.S. taxpayers more than $10 billion annually. Thirty-eight percent of African American girls and 36 percent of Latino girls who dropped out of high school in 2006 reported doing so because of pregnancy or parenthood. And only 40 percent of teens with children complete high school, with less than 2 percent finishing college by the time they are 30. Teen pregnancies levy an additional toll on young women and the U.S. public by contributing to these higher drop-out rates and reducing the potential lifetime income for teen moms.

Unintended pregnancy among women of all ages is a major drain on U.S. coffers. According to the Guttmacher Institute, public insurance programs paid for more than 60 percent of all births resulting from unintended pregnancies, with total public expenditures for these births totaling more than $11 billion in 2006. A number of studies have shown that by expanding contraceptive coverage to underserved communities, Obamacare would drastically reduce these expenditures.

Providing all women better care before and during their pregnancies is clearly the smart thing to do financially. It is also, plain and simple, the right thing to do. The UN says that access to family planning is a right that should be enjoyed by all women because it “permits the enjoyment of other rights, including the rights to health, education, and the achievement of a life with dignity.” Women fully understand that having the ability to control their bodies, preserve their reproductive and sexual health, and make fully informed decisions about when they will have children impacts their ability to thrive socially and economically.

The election may be behind us, but the battle for women’s health is far from over. States will continue to push back against the mandates of Obamacare and conservative legislators will continue to peel away at women’s health rights and their ability to access the care they need. Women in the United States must remain diligent as Obama begins his second term, reminding him, along with local, state, and national leaders that they demand and expect better health care and better health outcomes in the four years to come. They should do so because having affordable and accessible health care and the ability to make fully informed decisions about their bodies is a universal human right. And that is an idea that anyone invested in America’s long-term stability, strength, and security should embrace.

Andrea Flynn is a Fellow at the Roosevelt Institute.

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Mike Konczal: Is Occupy a Small Government Movement?

Nov 29, 2012

In the latest episode of the Roosevelt Institute's Bloggingheads series, Fireside Chats, Fellow Mike Konczal talks to Yale JD/PhD candidate Jeremy Kessler about the intersection of the law and the left and about

In the latest episode of the Roosevelt Institute's Bloggingheads series, Fireside Chats, Fellow Mike Konczal talks to Yale JD/PhD candidate Jeremy Kessler about the intersection of the law and the left and about leftists who dissent from mainstream progressivism. In the clip below, they discuss whether the Occupy movement, which Mike says has "made a comeback recently" with Strike Debt and Occupy Sandy, represents a libertarian rejection of the state rather than a progressive revolution.

Mike notes that despite Occupy's renewed vigor, some progressives continue to write "quasi-obituaries" that paint it as an aimless anarchist movement. Critics argue that "when you think of them creating a whole new world in Zuccotti Park" it sounds like "the gulches of Ayn Rand novels," and that "a lot of this focus on mutual aid essentially fills in for a rapidly receding government presence under neoliberalism." Mike says this can be seen with Occupy Sandy, which essentially serves as a replacement for FEMA, or the push for homeschooling, which is "just amplifying the way the state is privatizing and dismantling public education." But while Jeremy admits "there is a lot of allergy to the idea of centralized power" in the movement, he and Mike agree that it advances the left's cause by highlighting the failure of the neoliberal state and the "zones of privation" that the shrinking of government has created.

For more, including their discussion of the changing politics of the Supreme Court and the conservative police state, check out the full video below:

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Mike Konczal: Is Occupy a Small Government Movement?

Nov 29, 2012

In the latest episode of the Roosevelt Institute's Bloggingheads series, Fireside Chats, Fellow Mike Konczal talks to Yale JD/PhD candidate Jeremy Kessler about the intersection of the law and the left and about leftists who dissent from mainstream progressivism. In the clip below, they discuss whether the Occupy movement, which Mike says has "made a comeback recently" with Strike Debt and Occupy Sandy, represents a libertarian rejection of the state rather than a progressive revolution.

In the latest episode of the Roosevelt Institute's Bloggingheads series, Fireside Chats, Fellow Mike Konczal talks to Yale JD/PhD candidate Jeremy Kessler about the intersection of the law and the left and about leftists who dissent from mainstream progressivism. In the clip below, they discuss whether the Occupy movement, which Mike says has "made a comeback recently" with Strike Debt and Occupy Sandy, represents a libertarian rejection of the state rather than a progressive revolution.

Mike notes that despite Occupy's renewed vigor, some progressives continue to write "quasi-obituaries" that paint it as an aimless anarchist movement. Critics argue that "when you think of them creating a whole new world in Zuccotti Park" it sounds like "the gulches of Ayn Rand novels," and that "a lot of this focus on mutual aid essentially fills in for a rapidly receding government presence under neoliberalism." Mike says this can be seen with Occupy Sandy, which essentially serves as a replacement for FEMA, or the push for homeschooling, which is "just amplifying the way the state is privatizing and dismantling public education." But while Jeremy admits "there is a lot of allergy to the idea of centralized power" in the movement, he and Mike agree that it advances the left's cause by highlighting the failure of the neoliberal state and the "zones of privation" that the shrinking of government has created.

For more, including their discussion of the changing politics of the Supreme Court and the conservative police state, check out the full video below:

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The Fiscal Cliff Showdown Will Set the Agenda for the Next Four Years

Nov 16, 2012Richard Kirsch

As part of our series "A Rooseveltian Second Term Agenda," a look at the four biggest budget issues that will be debated in the next four months.

As part of our series "A Rooseveltian Second Term Agenda," a look at the four biggest budget issues that will be debated in the next four months.

The very next day after the election, congressional leaders held dueling press conferences in Washington to start the stampede to the fiscal cliff. But December 31st is not a cliff; it’s a slope. Actually, the better metaphor is a showdown between two different visions for the country – a showdown that will not only take place over the next four months, but will dominate debate about the economy for the next four years.

It is true that if Congress allows the tax hikes and spending cuts to be fully implemented, the economy will go into a tailspin, with four million people forced out of their jobs. But that won’t happen on January 1st. The impact of both tax hikes and spending cuts take time to accumulate. If Congress acts on taxes early in the year, it can make lower tax rates retroactive to the beginning of the year. Between federal contracts already in place and the time it takes to implement program cuts, budget cuts too will take a while before they slow down the economy. Better for Congress to walk down and back up the slope early in the year than be stampeded into bad decisions.

In this showdown we have a choice between two paths: prosperity for working families and the middle class or more for millionaires and CEOs. While the showdown will play out in the next few months, the issues will continue to set the economic agenda for the president’s second term. Both the immediate and continued battles will be over four issues: taxes, social insurance, federal discretionary spending, and investments to create jobs.

1. Taxes: The immediate battle will be whether or not to end the Bush tax rates on income over $250,000. The president has rightly made this his line in the sand. If Republican don’t budge, Democrats should wait until next year when all the Bush tax cuts expire, forcing House Republicans to continue to protect tax preferences for the wealthy while taxes go up on working and middle-class families.

The four-year agenda is to restore progressivity to the tax system. Progressives should define tax reform as taxing wealth at the same rate as income from work and enacting higher rates on the highest incomes. With corporate taxes the lowest they have ever been as a share of federal revenue, our agenda should be to end the loopholes and tax preferences for corporations that ship profits and jobs overseas and the breaks from exploiting our natural resources. We should raise more money from a loophole-free corporate tax system.

2. Social insurance: The big three social insurance programs – Social Security, Medicare, and Medicaid – are all protected from the automatic spending cuts, but that hasn’t stopped deficit hawks from trying to bring them into the upcoming debate. Changes to Social Security, like the Simpson-Bowles plan’s “adjustments” to the COLA that will result in 15 percent or more cuts in benefits to middle-class recipients, may well be put on the table as part of “grand bargain.” Democrats should follow Senate Majority Leader Harry Reid, who declared that Social Security is not on the agenda. Over the next four years, progressives should push for the obvious fix to the projected shortfall in the Social Security trust fund: raising or eliminating the cap on how much of earnings are subject to Social Security payroll taxes. That solution would extend the life of the trust fund to 2075 and beyond. It is politically popular, easy to explain, and fits within the broader progressive theme of a tax system that bolsters working families and the middle class by requiring a little more from those with more.

While Social Security does not add a dime to federal deficits, the same can’t be said of the rising pressures of health care spending on Medicare and Medicaid. Both programs should remain off the immediate fiscal showdown agenda, with Democrats pointing out that health care inflation over the past two years is at the lowest level in decades. Some of that is because of changes being put in place by the Affordable Care Act, which has a number of measures to control health care spending in Medicare by eliminating wasteful care and overpayments to health insurance companies. The big agenda for the next four years on health care is to continue to accelerate the changes put in place by the ACA, including that new panel – which the right likes to demonize – that will push Medicare to force providers to provide better care or see their revenues drop. Another top priority is for the federal government as well as states to follow what Massachusetts is doing: use the new health care marketplaces to review health insurance company rate increases and pressure health care providers to provide better quality care at lower cost.

3: Federal discretionary spending: The choice here is straightforward: the amount of revenue raised from ending the Bush tax cuts on income over $250,000 is almost the same as the total cuts to federal discretionary spending. Republicans are eager to stop the Pentagon’s half of the automatic cuts. While many Democrats want to protect the Pentagon, they also want to block the slashing of vital services for families and all the other things – from environmental protections to diplomatic functions – that the federal government does. Progressives should focus on those services that most support low-income and working families, like Pell grants, Head Start, WIC, and food stamps. These are very popular with the public and make the choice crystal clear.

In response to the Pentagon lobbying for more, progressives should argue that Pentagon spending can easily be trimmed, since even if the automatic cuts go through the Pentagon will still be spending more than at the height of the Cold War. Over the next four years, progressives will need to drive home the point that Pentagon spending creates far fewer jobs than spending on health care, education, and other domestic programs, so that reshaping the Pentagon for the 21st century makes both military and economic sense.

It is crucial that progressives link spending choices to jobs. For example, if unemployment insurance for the long-term unemployed is allowed to expire at the end of the year, the loss of benefits to 5 million people will result in another 448,000 being pushed onto the unemployment rolls in 2013. In fact, the biggest job losses among the many choices facing Congress would come from ending long-term unemployment insurance and cutting domestic spending.

4. Good jobs: One thing not on the immediate fiscal agenda is a program to create good jobs. It should be, as the sluggish economy and long-term decline in wages and benefits promises to keep millions of Americans out of work and a growing share of the workforce struggling to make ends meet. Progressive should use the fiscal showdown to go beyond highlighting the job impact of spending cuts. Instead, we should put forth a two-pronged jobs agenda and make this the central push for the next four years.

One prong is investment to create jobs: infrastructure, green jobs, “caring jobs” like day care, elder care, and putting more teachers in our classrooms. We should be pushing for a big youth jobs program. The second prong is job quality: restoring the rights of people to effectively organize unions, modernizing basic work standards by doing thing like raising the minimum wage and indexing it to inflation, and requiring all employers to provide a set number of paid sick days.

The Affordable Care Act will address the growing problem of jobs not coming with health care; here implementation is key. We should also be pushing for the establishment of a new retirement program, such as proposed by Senator Tom Harkin, under which workers would put aside a share of earnings in a pooled, professionally managed plan, with guaranteed, lifetime benefits at retirement or upon permanent disability.

The push for the comprehensive progressive economic agenda above – fair taxes, stronger social insurance programs, protecting vital public services for working families, and investment in good jobs – should start with the upcoming fiscal showdown. The battle between a vision of prosperity for working families and the middle class versus more for millionaires and CEOs is one we should wage for the next four years.

Richard Kirsch is a Senior Fellow at the Roosevelt Institute, a Senior Adviser to USAction, and the author of Fighting for Our Health. He was National Campaign Manager of Health Care for America Now during the legislative battle to pass reform.

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