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Republicans reject own health care plan 

This summer, some 115,000 Arkansans who have individual or employer insurance will get about $7.8 million in rebates for insurer overcharges in 2011. Most of them will cash the checks not knowing it resulted from the Affordable Care Act.

All the fury over Obamacare and the U.S. Supreme Court's decision upholding its constitutionality suggests that the law will drastically alter the lives of all Americans.

That is one of the many ironies of this epic battle, now in its fourth year. For the most part, the 15 percent of Americans who will be directly and significantly affected by the Affordable Care Act because they are not now insured seem to rather like the law's controversial provisions or accept them. It's the other four-fifths — the 170 million who are already fully insured by employer or individual policies and the nearly 100 million who are covered by one of the government programs — who are ready to storm the ramparts, for or against it, if you believe the polls.

Yet many, perhaps even most, of insured Americans will never be affected in a direct way, unless the law does succeed in one of its goals, which is to slow the growth of medical costs for one and all. Some are skeptical that the government will take the steps prescribed in the Affordable Care Act to get costs under control because many providers will oppose them. But it remains a hope.

There is, however, one sure direct effect: The law directs insurance companies to send rebates to policyholders each year when the companies spend more than 15 or 20 percent of people's premiums (depending on the size of the insurance pool) on administration, profits and executive bonuses rather than medical care. That means that this summer, some 115,000 Arkansans who have individual or employer insurance will get about $7.8 million in rebates for insurer overcharges in 2011. Most of them will cash the checks not knowing it resulted from the Affordable Care Act, and they will go on cursing Obamacare and the Supreme Court.

Indirectly, everyone who is insured now will benefit if everyone else becomes insured and his or her medical care is paid for, as the law intends. That will end or dramatically reduce the unreimbursed care at hospitals and clinics and end the cost shifting to the premiums of the insured.

That part of the law — the so-called mandate for people who are not insured and who earn more than 133 percent of the federal poverty line to buy insurance with government help — is the one that has caused the fury. It was the basis of all the suits challenging the constitutionality of the law on the theory that the commerce clause didn't expect government to ask people to buy insurance. (The government has been requiring people to buy insurance since 1935, when everyone was mandated to buy Old Age, Survivors' and Disability Insurance, and 1965, when they had to buy old age and disability health insurance.)

If you are young and healthy, you have a reasonable case for being sore that the country will ask you to buy insurance now rather than wait until you get sick. If your pay is not so swell, the government is going to pay a hefty part of the monthly premium for you — nearly all of it if your family income is very low.

But if you are insured and you and your employer are paying hefty premiums, don't you also have a case for being sore that all those people have gotten a free ride at the hospitals and clinics and that the costs are passed along every year to you in the form of another premium increase?

I referred to all the ironies of the Affordable Care Act battle. The most perverse is that the mandate that people buy insurance is the conservative and Republican formula. It was hatched by Ronald Reagan's think tank, the Heritage Foundation. It was the soul of the Personal Responsibility movement, embraced by Reagan and Bush I and then by Republicans in Congress in the great healthcare battle of 1993-94, lost by Bill and Hillary Clinton. Clinton reportedly wanted to join with the Senate Republicans on the private mandate but Hillary had too much invested in her plan, and the whole thing died. Monday, Mitt Romney, whose Massachusetts mandate law was the template for Obamacare, disagreed with his party and the Supreme Court and said the little penalty in the law for not buying insurance ($99 in 2014) was not a tax. It was not a tax when he prescribed the same thing in Massachusetts eight years ago.

You can see why tea partiers and others on the right would be upset about the other big feature of Obamacare, the expansion of Medicaid to cover most poor adults. That is government spending on the poor. Up to now, Republicans in Congress have been champions of Medicaid, but now that it is part of Obamacare they are forced to be against it.

Republican legislators in Arkansas, like those in Congress and in a few other states, were saying over the weekend that they would block state participation in the expanded Medicaid, which the Supreme Court said states could choose to skip without penalty.

At least for Arkansas, skipping it would be unimaginable: billions of dollars for Arkansas health care and the economy, none of it costing the state government a dime until 2017 and after 2020 costing the state 10 cents on the dollar.

You may wonder why Arkansas hospitals supported the law, joined last week by the chancellor of the state's medical school and hospital. For 2010, the last year for which figures are available, the uncollected bills and charity care at Arkansas hospitals totaled nearly $1.3 billion — people who were not insured and did not pay for their treatment. At the state medical center at Little Rock, the uncompensated care for the uninsured last year came to $175 million. Arkansas taxpayers picked up most of the bill for them through state and federal taxes.

Under Obamacare, Medicaid and the insurance mandate will end nearly all that cost shifting in 2014. Does that sound like something we should turn down?

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