09/30/2013 09:37 pm ET Updated Nov 30, 2013

The Real Death Panel in Obamacare? How About the GOP?

This past Friday, Congresswoman Michele Bachmann went on CNN to insist that death panels remain alive and well, so to speak, in Obamacare. In a world in which one could assume some plausible relationship between facts and a lawmaker's policy positions, it would be impossible to warn of death panels with a straight face. But we don't live in that world. So we get Bachmann essentially telling Wolf Blitzer on CNN that the Independent Payment Advisory Board (IPAB) -- which, in order to reduce Medicare costs, will make some judgments about what kinds of treatments are most cost-effective -- is a star chamber making life and death decisions about individual patients.

Of course, in the current system, bureaucrats who work for private insurance companies do make decisions all the time about who is to be granted treatment and who is to be denied it. Unlike IPAB - which will rule on categories of treatments and then give providers time to adjust accordingly, and whose decisions can still be overruled by Congress - these bureaucrats are making life and death decisions about patient care. And also unlike IPAB, those insurers aren't making such decisions because they believe the system as a whole will benefit from distinguishing more cost-effective from less cost-effective treatments. Instead, they are making decisions in order to save themselves money. Incidentally, this version of death panels is different from that which was originally floated by Sarah Palin. Palin's death panel canard derived from a since-stricken provision in the ACA incentivizing doctors to have conversations - yes, conversations - with patients about end-of-life directives and living wills. Calling that program 'death panels' is almost too stupid to believe. In any event, it did not make the final bill. Whichever version of death panels we're discussing, they are in the realm of sheer fantasy.

But there is a potentially mortal threat to Americans related to Obamacare - Republican-majority legislatures. At the federal level, of course, the GOP-controlled House appears prepared to shut down the government and perhaps default on our national debt in order to block implementation of a law that will extend affordable health insurance coverage to millions of Americans. At the state level, more than a dozen GOP-controlled state governments have rejected Medicaid expansion (with several more leaning toward doing so), an especially senseless and cruel decision that will, according to a Rand study conducted earlier this year, deny health insurance to several million people.

In North Carolina, my home state, Republicans rejected Medicaid expansion because, they insisted, the state couldn't afford it. In reality, the federal government will pay for virtually all of the expansion for the first six years and 90 percent thereafter. The result: the state would have enjoyed a net improvement in its budgetary position were it to have accepted expansion. Health care rejectionists also insisted it would be a job killer. In fact, it would have created tens of thousands of new jobs. Most fundamentally, with little cost to the state (and, in fact, with important ancillary benefits), a half a million North Carolinians would have been covered who now will not be.

In Kentucky, home to health-insurance deniers Mitch McConnell and Rand Paul, Democratic Governor Steve Beshear has laid out a clear and compelling case for why his home state needs Obamacare. He notes that over 600,000 Kentuckians, one in six, lack health insurance. They pray they don't get sick. They put off vital care. They have to choose between food and medicine. The consequences for the state include: "jacked-up costs, decreased worker productivity, lower quality of life, depressed school attendance and a poor image." Beshear cites analysis by PriceWaterhouseCoopers and the University of Louisville that shows what Medicaid expansion, in addition to covering over 300,000 people, will accomplish:

[an injection of] $15.6 billion into Kentucky's economy over the next eight years, create almost 17,000 new jobs, have an $802.4 million positive budget impact (by transferring certain expenditures from the state to the federal government, among other things), protect hospitals from cuts in indigent care funding and shield businesses from up to $48 million in annual penalties.

Such an obvious boon to the state leads Beshear to conclude: "The Affordable Care Act was approved by Congress and sanctioned by the Supreme Court. It is the law of the land. Get over it ... and get out of the way so I can help my people. Here in Kentucky, we cannot afford to waste another day or another life."

There has been a debate among health care experts about just how dangerous it is for individuals not to have health insurance and many factors are at play. But the vast majority of serious studies on the issue have shown a "strong[] link [between] insurance coverage and mortality rates". As the health economics expert Dr. Aaron Carroll has said about what's at stake here, states "can focus on how much they're willing to spend to save lives, but they shouldn't deny that that's what's at stake."

The GOP constantly excoriates liberals and Democrats for their welfare state fantasies because, Republicans insist, there is no such thing as a "free lunch" and that leftists don't understand that life involves hard choices. But the irony here is that Obamacare, for all its flaws, actually recognizes this and takes seriously the idea that there are tradeoffs. In order to help people of lesser means buy health insurance more affordably, some people are going to have to pay more. Increasing the Medicare payroll tax on wealthy Americans is one means of doing that. Insuring more people will require being a little skimpier with provider reimbursements. The ACA does that (and IPAB plays a role in cost containment as well). Since American doctors do extremely well by international standards, I think they'll manage. But that's a trade off. And yes, some younger Americans will pay more (though many fewer than the critics allege). When asked about the GOP "plan" for health care, one commonly hears that they agree 1) people shouldn't be denied coverage based on pre-existing conditions and 2) kids should be able to stay on their parents' plans until they're 26. Those happen to be two provisions of the law that poll especially well. So, why not pretend you support them. But how to pay for that? Republicans don't have an answer, other than hand waving about market competition. Unless you have a real mechanism to pay for the costs associated with providing insurance to more people who may be unwell, you don't have a serious plan for insuring a larger number of sick people. And if you can't offer such a plan, you can't really say you oppose denial of coverage based on pre-existing conditions, as pleasing as it sounds to be able to claim you do. Some prominent Republicans, like Newt Gingrich, acknowledge that the GOP simply doesn't have a meaningful alternative to the Affordable Care Act - only an unshakeable desire to kill it at all costs.

Thankfully, some Republican governors, including Arizona's Jan Brewer and Michigan's Rick Snyder, have chosen to do the right thing and accept Medicaid expansion. But the vast majority of GOP officeholders have committed themselves to a scorched-earth attack on expanding health insurance coverage, with all the adverse consequences such an attack entails. In so doing, the weight of the cumulative evidence shows, GOP-controlled governing institutions appear intent on consigning many Americans to poorer health, financial ruin and, in a non-trivial number of cases, death.

Thus, in the context of our current health care fight, if any entities can plausibly be characterized as death panels, it's them.