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Democrats’ Aim Should Be Universal Coverage – Improving the ACA is the Right Vehicle

Democrats’ Aim Should Be Universal Coverage – Improving the ACA is the Right Vehicle

I get why the liberal wing of the Democratic Party is obsessed with enacting Medicare-for-All as the vehicle to universal coverage. I do. There’s no question that if we got it right, it would be both far more equitable and cost-effective than the present chaotic patchwork of a “system” that we’re currently lumbered with. I was raised in England and I know what a blessing the National Health Service has been, warts and all, in providing first class health care to everyone and without driving any of anybody into bankruptcy.

I also understand only too well the frustration of forever being told that it simply can’t be done, that the odds are stacked against it. How do we know unless we try, right?

Nevertheless, reality must intrude. First, as we have already seen with the few states that have tried to add a public option to their ACA markets that the health care industry will wage total war on any suggestion of even a modest expansion of of a public health care option. And when I say the health industry, we’re talking the insurance companies, the hospital industry, the pharmaceutical industry and much of the medical profession, particularly specialists, surgeons and the hospitals each of whom gain the most from the present lack of price controls on any but Medicare patients, and who will fight tooth and nail to keep it that way. Added to the health industry’s implacable opposition will be the Republican Party and the entire right-wing universe complete with relentless fear mongering and lies. And they will have a powerful issue that lends itself to demagoguery. Socialized medicine! Egads!! The fact that they’ve called the ACA, modest insurance reform at best, the same thing will of course be lost in the din.

Second, a total reform of the entire US health care system, one that dwarfs the enactment of the ACA, will require the support of most Americans, 180 million of whom currently have employer-provided health insurance which most of them believe is just fine, thank you very much. And Democrats would be asking them to give that up and see their taxes increase to boot – a hard sell even though insurance premiums will go away. All of this on the promise that expanding Medicare to include everybody, entirely rationale but something we’ve never tried before, would be better. And then there’s the seniors who are currently well satisfied with their Medicare and will be scared into believing (by you know who – see above) that somehow they will lose much of what they have if their health care is folded into a national scheme for the whole population.

In short it will not merely be an uphill struggle to enact Medicare-for-all but the policy equivalent of free climbing Half Dome in Yosemite National Park and to believe otherwise is delusional.

But there are other ways to universal coverage. In fact there are many models among developed countries that have achieved and did so with a system that incorporates private insurance albeit heavily regulated. Switzerland is one, for example. Check this link to the non-partisan Commonwealth Fund for a thumbnail sketch of the Swiss system and that of other developed nations from whose systems we can draw lessons .

Which brings us to the Affordable Care Act. Like all compromises on huge and complex pieces of legislation, the ACA is manifestly imperfect and in need of substntial improvement, for example by vastly reducing out-of-pocket expenses and greatly expanding the income cut off to receive premium subsidies. Yet the law has significantly increased the number of people with health insurance whilst proving unexpectedly resilient in surviving GOP efforts to repeal it and the Trump administration’s attempts to weaken it. If Democrats win the White House and Congress in 2020, they have an opportunity to undo all the damage of the Trump era and to make the ACA a far bigger success in providing affordable health coverage to a vulnerable population.

As well, Democrats have other costly priorities to address such as climate change and relieving our kids of the huge debt burden of college loans, to name but two. A full throated battle for a single payer health system will suck all the political oxygen out of the air and leave us with little energy to seriously tackle those issues. And that would be a tragedy.

High price paid by states that did not expand Medicaid under Obamacare

High price paid by states that did not expand Medicaid under Obamacare

There has been no shortage of good news about the beneficial effects of the Affordable Care Act, particularly for those states that embraced it; and on the overall reduction in the percentage of uninsured adults in the country.

However, research by the Urban Institute also highlights the steep price paid by states that fought it tooth and nail, notably in the South.

For example, as of June 2014, 49% of the remaining uninsured adults in the United States live in the South, up from 41.5% before the act took effect in September 2013. Furthermore, almost 61% of uninsured adults reside in states that did not expand Medicaid under the ACA compared to less than 50% before the ACA.

And the bad news doesn’t stop there. The Urban Institute has quantified the billions in federal money lost by (mostly Red) states that rejected expanded Medicaid, as explained in this piece from Jonathan Cohn in the New Republic, again based on research by the Urban Institute. The excuse offered by Republican governors that they are simply being fiscally responsible is exposed for the nonsense it is by the map in Cohn’s piece.

Georgia, for example, saves $2.5 billion in what it would have spent to expand Medicaid over the course of a decade, but stands to lose $33.5 billion in federal funds, more than ten times as much. And of course it does nothing for the 20.2 % of Georgia adults who are still uninsured; in fact and as lamented in this piece from The Atlanta Journal-Constitution, the state now has the third highest rate of uninsured behind the perennial champs, Texas and Mississippi.

Talk about cutting off your nose to spite your face!

Mitch McConnell has nothing to offer Kentucky. He’ll be re-elected anyway.

Mitch McConnell has nothing to offer Kentucky. He’ll be re-elected anyway.

Kentucky is one of the poorest states in the union. It vies with West Virginia and Mississippi for bottom place in any well-being list. Its rates of poverty, obesity and general ill-health are among the worst in the country. It has high unemployment. And residents of Kentucky are among the most miserable in the nation, attributable in part to the high incidence of poor health.

In the 30 years he has served it as a United States senator, Republican Mitch McConnell, who is up for re-election this year, has provided little substantive help to the state. Oh sure McConnell steered a good chunk of earmark money to Kentucky over the years; but, as this Huffington Post profile on his career found, the money was directed scattershot fashion primarily in ways that would best cement McConnell’s own power and support in the state rather than as part of any strategy to enhance the state’s welfare. And since 2011 the earmark well has dried up, banned by McConnell’s own party in a largely symbolic show of fiscal rectitude.

Thanks to its Democratic governor’s wholehearted embrace of the Affordable Care Act, however, Kentucky stands to benefit enormously. Already about 360,000 people have signed up for health insurance under the ACA, of whom 75% were previously uninsured. All but 20,000 of the new enrollees are covered under the ACA’s expanded Medicaid, thanks to Kentucky’s low median income level and high poverty rate.

There are few states whose residents need it more. As the 24/7 Wall Street summary of the Gallup-Healthways Well-Being Index 2014 noted:

Kentuckians had some of the most unhealthy behaviors last year. Less than 60% of those surveyed said they ate well all day, the worst among all states, while the smoking rate was the highest in the nation. Unhealthy habits in the state likely contributed to poor physical health. Respondents from Kentucky were among the most likely to complain about lack of energy and sleep, and nearly 30% said health issues prevented them from going about their normal lives. The state’s population was the nation’s most reliant on prescription drugs, with 19.3 prescriptions filled per capita in 2011, tied with West Virginia.

And since approximately 640,000 or 17.5% of residents under 65 lacked insurance prior to the ACA, the law may be a game changer for a state that has traditionally struggled. While there is as yet no clinically proven connection between health insurance and good health, research indicates that having insurance coverage at the very least relieves stress and depression by ameliorating the strain of financial insecurity. Over time it is not unreasonable to hope that the expansion of health coverage in Kentucky will have an enormously significant and positive impact on its population’s well-being.

One would think that this might change the political landscape in this very conservative state. After all a law passed by Democrats in Washington and implemented brilliantly in Kentucky by Democratic Governor Steve Beshear through a remarkably trouble-free website, is already benefitting scores of thousands and has reduced the rate of uninsured by over 40%.

Alas not so. Hatred for Obama and anything associated with him overshadows any actual benefit from the ACA. According to Yahoo News:

Far from being seen as a success story, though, in Kentucky, the health care law and Beshear’s strong embrace of it remain deeply controversial. A recent poll showed that a plurality of Kentuckians continue to favor repealing the law. Other than Beshear, many of the state’s leading Democrats, aware of the lingering tensions around the ACA, avoid speaking about it publicly, wary of being seen as too supportive of “Obamacare.”

Assuming McConnell survives a GOP primary challenge, his Democratic opponent in November will be Allison Lundergan Grimes. In a rational world, Grimes would be trumpeting the success of the ACA in Kentucky and its promise of a better future for so many. Instead:

Alison Lundergan Grimes, the Democrat challenging McConnell in a closely watched U.S. Senate race, does not include any mention of the law on her campaign website and has avoided associating herself with Beshear’s embrace of it.

The Economist wonders:

Why are Kentucky Democrats running away from a law that has for the first time brought free or affordable health insurance to hundreds of thousands of their constituents— mainly at the expense of wealthy out-of-staters? This is one of the poorest, unhealthiest, least-insured states in America, the state with the fourth-highest rate of Social Security disability status in the country, a state that is a byword for cancer-ridden smokers and black-lung-plagued coal miners. Why, among these voters especially, is Obamacare such a losing issue?

Because it was conceived and passed by Democrats and pushed by a black Democratic president, that’s why.

McConnell, of course, has nothing to offer Kentucky but his usual manipulations of the feeble-minded on issues like gun-control, and the promise to repeal a law that stands as the most positive development for the welfare of ordinary Kentuckians in a generation or more. Yet Grimes is a distinct underdog and current trends suggest that Democratic office holders will soon be rarer than unicorns in the state.

In his trenchant book, Thomas Frank asked the question: What’s the Matter With Kansas? People in Kentucky should be asking the same question of themselves.

America has the best healthcare system in the world! (Except a few people do slip through the cracks…)

America has the best healthcare system in the world! (Except a few people do slip through the cracks…)

Watch this Aasif Mandvi video from last Thursday’s Daily Show featuring an interview with Fox Business Commentator Todd Wilemon. At the 3:35 mark Aasif Mandvi sets up Wilemon with a report of an unhealthy population in a place with very limited access to quality healthcare. Wilemon thinks he is describing a situation in a third-world country. At the 4:12 mark watch Wilemon grapple with a severe case of cognitive dissonance when  he learns the community Mandvi is describing is Knoxville, Tennessee.

 

What happens to Wilemon is what happens to all Republicans when facts about pretty much anything don’t match up with their unsubstantiated beliefs in American exceptionalism.

Wilemon froze as the contrary evidence penetrated his skull and ricocheted around his cranium. After some moments of uncomfortable contemplation, he responds with, “you know people do fall through the cracks”. To say otherwise would be to admit that America doesn’t have “The Best Healthcare System in the World“, and to admit that would cause his head to explode so, in an act of self preservation, he grabs hold of that inconvenient thought in his head and shoves up his ass where he thinks it belongs.

Wilemon recovers a bit and then argues that the healthcare-deprived people in Knoxville are unhealthy because they chose not to buy healthcare. At the 5:30 mark Mandvi delivers another bullet to the cranium with,”because they can’t afford it”, and “So if you’re poor, just stop being poor”. It is of course and absurd statement, unless you’re a Republican. Then it’s “a good idea”.

Republicans and their mouthpieces on Fox News cannot accept that America doesn’t have the best healthcare system in the world. They don’t believe the Number 37 ranking. They can’t believe it because they lack empathy for anyone not like themselves. Live in poverty? Your fault! Got sick? Your fault! Don’t have access to a healthcare network? Get a job! And stop being poor because you are ruining my fantasy.

The Affordable Care Act helps those in states that embrace it.

The Affordable Care Act helps those in states that embrace it.

There’s some dispute on the number of people who have gained health insurance since the Affordable Care Act came into effect but it is clearly near to the 10 million figure than some commentators have estimated. That number includes enrollees through federal or state private insurance marketplace exchanges, those who enrolled in Medicaid or young adults who have stayed on the insurance plans of their parents.

Interesting new data from Theda Skocpol, professor of government and sociology at Harvard University and director of the Scholars Strategy Network show that, to date, the benefits of the health law have accrued disproportionately to states that have fully embraced the law (see graph) and least to the states that have eschewed it.

EGACC Chart

As Dylan Scott puts it in Talking Points Memo:

The difference between the top and the bottom groups tells the whole story. Those states, like California and New York, that have fully bought into the ACA have performed exceedingly well in enrolling their citizens. They’re already 43 percent of their way toward their projected Medicaid enrollment, as calculated by Skocpol, and 37 percent of the way there on private coverage.

But as involvement goes down, so does enrollment. Those states, like Florida and Texas, that decided to opt out completely have only enrolled 1.5 percent of their potential Medicaid population if they had expanded the program as originally planned. By leaving their citizens to deal with problem-plagued HealthCare.gov, private enrollment is struggling, too: Only 5.6 percent toward the mark.

Of course as the efficiency of Healthcare.gov continues to improve and we draw nearer to the March 31st enrollment deadline, it is to be hoped that numbers for the lagging states spike. Nevertheless, the stubborn refusal of 25 states to expand Medicaid under the ACA and the overall obstructionist attitude of most Republican governors and state legislatures, means that many millions of Americans living in mostly Red States will lack the health insurance that could easily have been theirs.

The overlooked benefit that is the real promise of the Affordable Care Act – for all of us.

The overlooked benefit that is the real promise of the Affordable Care Act – for all of us.

The chaotic rollout of the main provisions of the Affordable Care Act beginning with the failed federal and some state websites has obscured a fundamental and crucial benefit that accrues to all of us on 1st January 2014: none of us need ever again be compelled by circumstances to do without health insurance for ourselves or for our families, as this insightful piece earlier this month by Ezra Klein in The Washington Post highlights.

When full implementation of the ACA commences on January 1st, being laid off in America, or quitting employment to become self-employed, or retiring prematurely to pursue other interests, will not mean losing one’s health insurance. By creating an individual private insurance market that prevents the exclusion of anyone based on a pre-existing medical condition, and by providing subsidies to those with a middling income or eligibility for an expanded Medicaid for low-income adults, the ACA ensures that being laid off will no longer be quite the unmitigated disaster it has been until now for American workers. Like their counterparts in other industrialized countries, Americans will be assured of reasonably affordable health care coverage regardless of their employment status.

This is a huge deal because it will add immeasurably to the sense of security of most American workers – once they figure out what it all means. In the din that has accompanied the ACA’s rollout, however, the law’s benefits (and this one in particular) have not received much of a hearing. However, once things settle down in the New Year, it should become increasingly obvious to more and more people that the ACA represents a very significant strengthening of the social safety net, one that ultimately benefits all of us and not just the uninsured.

Reports of Obamacare’s demise greatly exaggerated.

Reports of Obamacare’s demise greatly exaggerated.

To listen to Republicans, pundits and much of the media, the Affordable Care Act is already gasping for air; emitting what many hope is its death rattle. For Republicans and Fox News, Christmas has clearly come early thanks to the botched rollout (how many times have we heard or seen that phrase?) of the landmark health law.

The latest polls show that both President Obama and his signature legislative achievement have taken a serious hit. Some Democrats have already assumed that defensive crouch that seems to come so naturally to them when the going gets rough – witness the 39 cowards in the House who, disgracefully, voted for a GOP bill that would have seriously undermined the ACA.

The federal website’s dysfunction was bad enough but Obama’s inaccurate assurances that everyone who had insurance and a doctor they liked could keep them, making no exception for the mostly rubbish individual policies that failed by a country mile to meet even the modest basic requirements of the ACA, created an instant political storm. To make matters worse, this last problem was compounded by the failure of the website since those who had received policy cancellation letters were stymied in their efforts to find a new policy that would likely be both affordable (when subsidies were factored) and more comprehensive in most cases.

No question this was not the place those who support this law wanted to be at this point. Nevertheless, it is way too early to panic and even more absurd to speak of the law’s demise.

Amid the media hype and feeding frenzy that’s been targeting the administration’s missteps in the initial implementation of the law (where is that “liberal media” when you need it?) the steady progress being made in states that have embraced Obamacare has been largely overlooked, as this piece in The Washington Post by the governors of Washington State, Kentucky and Connecticut highlights and this piece from The Los Angeles Times.

Fourteen states plus the District of Columbia have their own health insurance exchanges and most of these are operating smoothly (Oregon’s is not functioning at present although the state has enrolled 70,000 newly eligible people into Medicaid). There is every reason to believe that enrollment in these states, which constitute about a third of all Americans, in both the private exchanges and in expanded Medicaid will continue to pick up. For all the current furor over the website’s problems, the angst that has accompanied the issuance of cancellation letters to a much smaller segment of the insurance market than the one which will benefit unambiguously from enrollment under the ACA, raises the following question: Who exactly is going to tell these new enrollees and the millions more to come, that their insurance will be cancelled? The answer is: Nobody.

Republicans were desperate to kill the ACA before it could be implemented because they feared that once the number of beneficiaries had reached a sufficient level, it would be impossible to turn back the clock. That dynamic has not changed, irrespective of the rollout issues. Furthermore, there is nothing in what has happened so far to cast any significant doubt that the law will not work as intended.

However, it is becoming clear that the benefits of the law will not be spread evenly throughout the country. For example, the populations of the fourteen states plus DC who have wholeheartedly embraced Obamacare stand to see a large reduction in the number of uninsured sooner rather than later over the next 1-3 years. It’s not merely that these mostly Blue States (Kentucky being the exception) have established their own exchanges and agreed to the Medicaid expansion. It’s that they also are putting federal and their own resources to work with communication and outreach strategies to enroll as many of their eligible residents as possible.

At the other end of the spectrum, we have the twenty-one states (four others are undecided) who have refused both the Medicaid expansion or to establish their own exchanges. For the folks in these GOP-led states, the adverse consequences go well beyond the current difficulties with the federal website. Some states have actively impeded the work of organizations and individuals tasked with providing information and assistance (“navigators”) to residents who may be eligible for enrollment under the ACA. This lack of cooperation combined with constantly talking down the law will inevitably have the effect of dampening enrollment.

Furthermore, a significant number of working poor in the Red States who would have qualified under the Medicaid expansion that their states have refused, will also be ineligible for federal subsidies with which to purchase a private plan on the exchanges because their incomes do not meet the minimum threshold. How’s that for a double whammy, compliments of their Republican legislators and/or governor.

The bad news for the poorer residents of these Red States does not end there, however, as this story from The New York Times shows. Hospitals in mostly rural areas which provide safety-net care for many without health insurance are seeing their federal subsidies slashed because it was assumed that the beneficiaries would be covered under the Medicaid expansion. Some of the hospitals have closed or may do so without the subsidies. Needless to say the GOP governors and legislators in these states are not picking up the slack.

The fact is that for many millions of Americans, Obamacare holds the very real promise of freedom from the insecurity and stress that comes from lacking health care coverage. However, that benefit will only accrue nationally if all states recognize the enormous opportunity offered by the ACA to make the lives of our citizens better and more secure.

Obamacare’s overdue reform of a lousy private health insurance market.

Obamacare’s overdue reform of a lousy private health insurance market.

We’re hearing an awful lot from and about those in the private health insurance market who are receiving policy cancellation letters with lots of heat but little light being shed on what is a serious issue. Much of the focus has been on President Obama’s repeated and misleading assertions that everyone would be able to keep their existing insurance plan and doctor. Perhaps mindful of the fact that, more often than not in America, nuance falls on deaf ears, he foolishly neglected to make a distinction between employer-provided insurance plans, which will be unchanged, and those purchased on the individual market which constitute about 6% of the insured overall.

Republicans who have been and continue to be unmoved by the plight of the uninsured are apoplectic in behalf of the people in this small segment of the insurance market who are losing their current insurance plans. This selective outrage is driven, of course, by their desperate desire to seize on anything that can help them destroy the Affordable Care Act.

The Washington Post’s Ezra Klein is one who has successfully put the issue in some perspective and his detailed analysis is a must read.

The individuals and families affected and whose plans fail to meet the requirements of the ACA, broadly fall into two categories. The first group has lousy insurance plans with features such as high deductibles, limited coverage and low caps on total expenditures by the insurance company, that ensure crushing out-of-pocket expenses in the event of a chronic or acute illness requiring serious and expensive treatment. The cancellation of these policies is an unequivocally good thing since such bare bones plans offer little security to the policy holders and cause higher costs to health providers and ultimately to the rest of us. The ACA will almost certainly provide much better, affordable plans once subsidies for those who qualify are factored. These people have little to complain about.

The second group, however, has a genuine beef. They are generally healthy, middle aged or older folks who have a decent insurance plan which, nevertheless, does not meet the ACA. Some of them, as highlighted in Klein’s story, have received cancellation letters and been unable to find a plan as good as the one they are losing at a comparable price either in the exchanges (assuming they’ve been able to check the federal website if they reside in a state without its own exchange) or from their current carriers. If they have a decent income they don’t qualify for subsidies.

Regrettable as their situation may be, it has to be kept in perspective. As Klein points out, these people have benefitted enormously from the ability of insurance companies to exclude others from coverage that had pre-existing conditions. By excluding these poor risks, insurance companies were able to offer more favorable plans to those who are now vexed by seeing them cancelled. A further consequence is that some of those who previously benefitted from the dysfunctional and rather pitiless individual health insurance market will likely pay more for less under the ACA, as appears to be the case for the individual mentioned at the beginning of Klein’s piece.

It is likely scant comfort for this group to know that many more people will gain health coverage previously denied them under the reformed private insurance market, and that others will get better, more comprehensive plans than they had before. Nevertheless, for the country as a whole and the cause of social justice, it’s a very worthwhile tradeoff.

Today’s seniors must not be exempted from any major changes to Medicare

Today’s seniors must not be exempted from any major changes to Medicare

There are signs that House Republicans, led by John Boehner, are pivoting away from employing extortion to force President Obama and Senate Democrats into defunding or delaying the Affordable Care Act as a price for re-opening the government and raising the debt ceiling and, instead, will be the using similar extortion to force concessions on the budget. Primarily these will be through cuts to entitlements, notably Medicare.

Looking forward to that happy time when the GOP and Democrats sit down to negotiate the budget without the latter having a gun put to their head as a bargaining incentive, the issue of Medicare reform will be front and center and so I have a suggestion that should move things along: Agree that any changes to the program apply to current Medicare recipients as well as future beneficiaries.

Why? Well in the GOP’s plan contained in Congressman Paul Ryan’s ten-year budget, he changes traditional Medicare to an income-support program – which is a fancy way of describing a voucher. Seniors would be given an amount of money and told to go find a plan they like in the private insurance market. A summary of the Ryan plan as reintroduced earlier this year follows, courtesy of CNN Money:

Workers who turn 65 in 2024 or later would be able to choose between a variety of private health insurance plans, along with the traditional Medicare option. They receive a subsidy from the federal government to cover or offset the cost of their Medicare premium.

The subsidy would cover the cost of the second-least-expensive private plan or the Medicare option, whichever is less, in the first year. So if seniors select pricier coverage, they would have to pay the difference in cost. And they would receive a rebate if they selected a cheaper plan.

After that, the subsidy increase would be based on a competitive bidding process, but the per capita hike would be no more than nominal GDP growth plus 0.5%. That currently works out to about 4.5% based on figures for 2012.

Lower-income seniors would be protected, while wealthier ones would pay a higher share of their premiums.

Setting aside the pros and cons of Ryan’s plan, you will note that it doesn’t kick in until 2024! This may seem perplexing in light of the apparent urgency placed on Medicare reform by the GOP as a way to reduce future deficits. So, why the delay, one might ask, given the imperative to find these savings?

Well the GOP has done quite well in recent elections among (mostly white) seniors, winning close to 60% in both the 2010 mid-term elections and the 2012 presidential election; and this despite their continuous assertions of the need to rein in entitlements. A clever trick but how have they managed it?

Well in large part because the GOP has a nudge-nudge, wink-wink thing going on with their cranky white senior support group. Republicans have let it be known that while they still want Medicare gutted, they’ll delay the gutting for a decade and grandfather in today’s seniors and those soon-to-be who can keep their current Medicare benefits. From 2024 new seniors will be lumbered with the voucher plan. Thus reassured, our current generation of selfish old codgers can happily vote Republican and the least informed among them denounce Obama for pushing the government to get its hands on their Medicare. (And even GOP congressmen seem to have trouble understanding that Medicare is a government program – see this piece from Gail Collins, a must read).

However, the GOP cannot argue with a straight face that on the one hand reforming Medicare is a critically urgent need but that on the other it can wait for a decade. Therefore, when the two sides eventually sit down to serious negotiations about entitlements, let’s not hear any more about ten-year phase-ins for Medicare reform. After all, even the ACA is being implemented after just three.

The Republican voucher plan for Medicare deserves a hearing and serious scrutiny. But any plan, including Ryan’s, should be seen to be acceptable to today’s seniors and not just tomorrow’s to ensure that future retirees are not given the shaft. After all, it’s only fair.

And having to produce a plan that passes muster with today’s seniors may actually bring the two sides closer together more quickly and make it a bit easier to come to some agreement on Medicare reform – albeit I suspect minus the voucher.

Mitt Romney’s Campaign: Dishonest and Insulting

Mitt Romney’s Campaign: Dishonest and Insulting

There are plenty of positive reasons for re-electing President Barack Obama next Tuesday week and these have been described eloquently elsewhere. For some of the best and most thoughtful, see Fareed Zakaria in The Washington Post and recent editorial endorsements from the Post and The New York Times. For the most thoughtful analysis also check out the latest edition of the The New Yorker magazine.

To summarize, Obama inherited a gigantic financial collapse from his predecessor that threatened an economic collapse of Great Depression proportions, and a country whose standing in the world had greatly diminished in the wake of the disastrous invasion and occupation of Iraq, and the torturing and indefinite detention of suspected terrorists in Guantánamo and secret CIA prisons.

After four years, America’s standing is largely restored (Guantánamo, alas, remains in operation but the US now follows international law in the treatment of detainees) and the economy is slowly growing thanks largely to a highly effective stimulus package, that placed a floor under its precipitous descent, and well-managed automobile and banking industry bailouts; this, despite strong headwinds from poorly performing economies in Europe and elsewhere.

Yet even if the positive case for Obama failed to convince a wavering voter, the nature of his opponent should make this election a no-brainer.

Mitt Romney has lied and flip-flopped his way through this campaign in a manner that is both unprecedented and breathtaking. For Romney, truth and principle have been about as welcome as ex-girlfriends with halitosis in his efforts to win the presidency and tick off that final box on his career to-do list.

This political chameleon has morphed from a 1990’s moderate who supported a woman’s choice on abortion, who believed in an individual mandate for his state’s Obamacare-like health insurance reform law, who understood that relying on emergency rooms as a substitute for health insurance made no sense, who had progressive views on immigration, gun control and Lord knows what else, into a “severe conservative” who would take women’s health choices away from them, including the right to decide whether to have an abortion, who has become the NRA’s best pal, who will undo a national health insurance reform law modeled on his own in Massachusetts, and who will slash government programs for the neediest Americans so that those in his own class cannot only continue to enjoy their low tax rates but see them lowered still more; a man who will shred the social safety net while spending badly needed dollars on ships the navy doesn’t want or need. Oh and maybe start a war with Iran under prodding from his good buddy, Bibi Netanyahu.

He has been utterly dishonest about President Obama and his own plans. Treating fact-checkers as a sort of white background noise, Romney repeatedly tells whoppers such as Obama’s imaginary “apology tour” around the world or about the stimulus that made the economy worse when independent and authoritative analyses have effectively debunked both claims. He parrots the ideology of the most extreme adherents of what has become an extremist GOP which has no commonality with or similarity to any conservative party in the industrialized world.

The most shocking aspect of all this is how incredibly insulting it is to the American electorate. Some of his contempt was captured in his unguarded comments before a group of wealthy donors in the now famous video in which he dismisses 47% of voters as losers and freeloaders. But beyond dividing the country into strivers and whiners, Romney is also saying without actually voicing the words: I know I can tell lies about my opponent and you people will have no clue; I know I can promise to cut taxes across the board, raise spending on defense and reduce the deficit simultaneously and you idiots won’t realize that the math makes it impossible without eviscerating every other government program you can think of. And I can promise the moon without giving a single useful detail about any of it and you bozos will still elect me president.

I guess a week from Tuesday we’ll see if he’s right.