Slightly Skeptical View on Health insurance

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It's hard to find products, services and companies that provide honest health service, good monitoring devices and, in general, quality products. This is especially true about medical insurance. Everything (or almost everything is spoiled by obsessive, destructive marketing). Not only USA health system is drug obsessed and test driven to the extent that serious mistakes are possible, it is based of strange symbiosis between doctors and health insurance companies in which each party tries to fool the other. In addition, many doctors became more pharmacy salesmen then real health specialists.  This father complicates the picture. 

In fact, anybody with health problems need to participate in complex poker match between insurance and doctors where you just a minor card.  There are several dangers here

Distortions created by the US healthcare model

This is a very complex issue but some visible problems are as following:

None of these key issues is addressed by the new legislation, hence the support from the Pharmaceutical Companies and Insurers. Nothing will change and the US will continue to pay double the share of GDP with worse outcomes in comparison to other developed countries.


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[Feb 19, 2017] As Democrats stare down eight years of policies being wiped out within months, but those policies did virtually nothing for their electoral success at any level.

Notable quotes:
"... This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples. ..."
"... missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium.. ..."
Feb 19, 2017 | economistsview.typepad.com
Peter K. -> Chris G ... , February 18, 2017 at 07:35 AM
via J.W. Mason (lots of F-bombs!):

http://democracyjournal.org/arguments/keep-it-simple-and-take-credit/

Keep It Simple and Take Credit

BY JACK MESERVE
FROM FEBRUARY 3, 2017, 5:42 PM

As Democrats stare down eight years of policies being wiped out within months, it's worth looking at why those policies did virtually nothing for their electoral success at any level. And, in the interest of supporting a united front between liberals and socialists, let me start this off with a rather long quote from Matt Christman of Chapo Trap House, on why Obamacare failed to gain more popularity:

There are parts to it that are unambiguously good - like, Medicaid expansion is good, and why? Because there's no f!@#ing strings attached. You don't have to go to a goddamned website and become a f@!#ing hacker to try to figure out how to pick the right plan, they just tell you "you're covered now." And that's it! That's all it ever should have been and that is why - [Jonathan Chait] is bemoaning why it's a political failure? Because modern neoliberal, left-neoliberal policy is all about making this shit invisible to people so that they don't know what they're getting out of it.

And as Rick Perlstein has talked about a lot, that's one of the reasons that Democrats end up f!@#$ing themselves over. The reason they held Congress for 40 years after enacting Social Security is because Social Security was right in your f!@ing face. They could say to you, "you didn't used to have money when you were old, now you do. Thank Democrats." And they f!@#ing did. Now it's, "you didn't used to be able to log on to a website and negotiate between 15 different providers to pick a platinum or gold or zinc plan and apply a f!@#$ing formula for a subsidy that's gonna change depending on your income so you might end up having to retroactively owe money or have a higher premium." Holy shit, thank you so much.

This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples.

...

ilsm -> Peter K.... , February 18, 2017 at 12:47 PM
missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium..

[Feb 01, 2017] The dangers of repeal of obamacare

Feb 01, 2017 | economistsview.typepad.com
EMichael : January 31, 2017 at 05:34 AM
Meanwhile, have you noticed this from Drum?

"I've written before about the possibility that repealing bits and parts of Obamacare-which is all Republicans can do-will destroy the individual insurance market. Not just the Obamacare exchanges, but the entire market. Insurers would still be required to insure everyone who applies for coverage, but there would be no subsidies and no mandate. The result would be a flood of super-expensive patients like me, and virtually no healthy people to balance out the pool. If that happens, insurers will simply exit the individual market rather than take huge losses

Here's the only reaction I could find from the insurance industry:

"At a time when the individual market faces challenges, we need as many people as possible to participate - so that costs go down for everyone," said Kristine Grow, spokeswoman for America's Health Insurance Plans.

This wasn't even a reaction to Obamacare repeal, either. It was a reaction to the Trump administration's childish attempt at sabotaging signups for 2017. Basically, the insurance industry has been curiously quiet about the whole thing.

Why? They know the stakes better than anyone. Recent premium hikes hold out the promise that after years of losses, their Obamacare business will finally turn profitable this year or next. But a ham-handed repeal effort does just the opposite. The individual market would become massively unprofitable, and insurers would have to decide whether to ride it out for a year or two, or simply abandon the individual market altogether. These are really lousy alternatives."

http://www.motherjones.com/kevin-drum/2017/01/insurance-industry-curiously-quiet-about-obamacare-repeal

I think I know the reason for the insurance company's silence. They want to go back to the old way. Sure, if the ACA stays in place as it is, they are OK and will profit once they find the proper premium levels. But with what the Reps have already done to the ACA they doubt the program can move forward, especially now.

But even if the Reps just let it stand(which they won't), the insurance companies have figure out that they would be far better off with the old private markets of high deductibles, pre existing condition bans, recissions and cancelling of policies once the holder gets sick.

Combine that with losing medical loss ratios on both private and employer provided insurance and it would be a bonanza for health insurance companies.

So they stay silent(in public anyway) cause no matter what happens they make out, and this way it seems like they are just following orders and working to "help" the public.

Peter K. -> EMichael... , January 31, 2017 at 05:44 AM
Don't people argue that if we go back to the old way, that the entire system will collapse and we'll get single payer eventually after many painful years?

Trump and that clown Stephen Moore keep talking about competition across state lines but I don't see that happening.

DeDude -> EMichael... , January 31, 2017 at 06:38 AM
ObamaCare required a lot of things, including that they didn't use more than 20% of the premiums on profits. They couldn't just be a scam collecting premiums and kicking people off their plans if/when they got sick. In the old model it was a lot easier to make fat profits out of the asymmetrical knowledge between them and the marks.
EMichael -> DeDude... , January 31, 2017 at 06:54 AM
If the insurance companies thought that medical loss ratios would make it into the bill, they would never have allowed Lieberman to break the filibuster.

Meanwhile, over at Angry Bear, Run has a great post.

http://angrybearblog.com/2017/01/38918.html

I am not sure whether the House is the only one that can change their rules to avoid a CBO analysis. Trying to find out.

DeDude -> EMichael... , January 31, 2017 at 07:22 AM
Yes banning the CBO from scoring repeal and revealing that it is a big budget buster - was a classic GOP trick (keep the people uninformed before you screw them). I agree that it is a little surprising that democrats have not yet gotten the big guns our and pointed out how MediCare will go bankrupt when ACA is repealed. There must be some tactical calculation there. They probably want that perfect storm of scared seniors to call their Senators at a specific time when it will be most likely to tip over the wagon.
DeDude -> DeDude... , January 31, 2017 at 07:26 AM
The GOP repeal of ACA will bankrupt MediCare and Paul Ryan doesn't want you to know about it !!!!!!!!!!!!!!!

Write your Senators and write your representative demanding that they reveal all the details of their nefarious plans.

pgl -> DeDude... , January 31, 2017 at 08:30 AM
"more than 20% of the premiums on profits"

Gross or operating? Operating profit margins are only 8% (4 times greater than a competitive return). Gross margins include the bloated operating expenses. Think X-inefficiency.

pgl -> EMichael... , January 31, 2017 at 08:29 AM
"Combine that with losing medical loss ratios on both private and employer provided insurance and it would be a bonanza for health insurance companies."

One minus the medical loss ratio is the gross profit margin for these oligopolists. This margin should be less than 10% for reasons I have noted before. But wait - they now exceed 20%. What one gets when one allows unfettered monopoly power.

EMichael -> pgl... , January 31, 2017 at 08:45 AM
No, they do not exceed 20%. That is the max in the private market, 15% in the employer market.
DeDude -> EMichael... , January 31, 2017 at 09:13 AM
I should have been a little more precise. "The 80/20 rule requires insurance companies to rebate any excess premium charged if they spend less than 80% of premiums on medical care and efforts to improve the quality of care"

https://www.cms.gov/CCIIO/Resources/Files/Downloads/mlr-report-02-15-2013.pdf

So it includes everything including administration.

[Jan 21, 2017] Assessing Obama healthcare track record

Jan 21, 2017 | www.jacobinmag.com
Over his two terms, Barack Obama signed a number of major health-care bills into law, most significantly the Affordable Care Act of 2010 (ACA), though also more recently the 21st Century Cures Act of 2016. Though the GOP's coming assault on health care is likely to be heartless - and though resistance to it must be resolute - we would be better served by a sober assessment of Obama's health-care legacy than by triumphalist acclaim of such laws.

The ACA, passed without any Republican votes, has had a significant impact on health-care access: mainly through the expansion of Medicaid together with the subsidization of private health insurance, it achieved a partial reduction in the number of the uninsured, from 48.6 million in 2010 to 28.4 million in early 2016 (still an enormous number!), according to National Health Interview Survey estimates . Other provisions of the law, like those eliminating co-payments for some preventive care or banning preexisting condition discrimination, benefited many more.

Yet those who trumpet such gains while scratching their heads at the law's relative unpopularity are missing the crux of the problem: despite President Obama's reforms, the health-care system continues to fail much of the nation.

One example: in Canada, physicians and hospitals are free when you use them. In the United States, co-payments and deductibles for such care (which average $7,474 for a family marketplace silver plan) often rations medical care by economic status. Studies have shown that those with inadequate insurance avoid going to the ER even when they need it, delay care when in the throes of a heart attack , and face financial strain and sometimes bankruptcy when sickness strikes. Such injustices preceded the ACA, but because the law failed to fix them, it is blamed - fairly or unfairly - for their persistence.

More recently, Obama signed the 21st Century Cures Act into law, which among other things incrementally reduced the rigor of the Food and Drug Administration's drug approval process. These provisions were tantamount to a generous handout to the pharmaceutical industry, which had lobbied heavily for the bill. Not surprisingly, it also did precisely nothing about sky-high drug costs .

This is a decidedly mixed legacy. The gains of the ACA are evident: indeed, for some of those who gained coverage, it was lifesaving. Its shortcomings, however, are equally evident: some twenty-eight million uninsured, persistently high cost-sharing, inequalities in access, uncontrolled drug prices, and so forth.

Of course, Republican designs, whether repeal and/or modification, will only make things worse. When that happens, we should dub the resultant fiasco GOP-Care, and blast it for all its injustices. However, it should also be clear that "Let's go back to 2016" will not be a winning campaign slogan for Democrats in coming elections: people want - and deserve - real change.

To defeat GOP-Care, we will need a more powerful weapon than Obamacare. For this reason, the time to push for universal single-payer health care is right now

-Adam Gaffney

[Jan 18, 2017] The Biggest Changes Obamacare Made, and Those That May Disappear

Jan 18, 2017 | economistsview.typepad.com
Fred C. Dobbs : January 15, 2017 at 08:37 AM , 2017 at 08:37 AM
The Biggest Changes Obamacare Made, and Those That
May Disappear https://nyti.ms/2itydsr via @UpshotNYT
NYT - Margot Sanger-Katz - January 13, 2017

It looks like the beginning of the end for Obamacare as we know it.

After years of vowing to repeal the Affordable Care Act, as it is formally known, Republican lawmakers in both chambers of Congress have now passed a bill that will make it easier to gut the law.

Because they are using a special budget process, Republicans won't be able to repeal all provisions of the health law. But it seems like a good time to look at the major changes Obamacare brought to health care, which of those changes may now disappear, and what might replace them.

An important note: We still don't know the details of a repeal bill, and passage is not guaranteed. But Republicans passed a similar package in 2015, vetoed by President Obama, that provides a rough template. Republicans have also said they hope to make further changes through additional legislation. We'll provide updates when new legislative language arrives, expected in several weeks.

1) Obamacare insured millions through new insurance markets.

The health law reduced the number of uninsured Americans by an estimated 20 million people from 2010 to 2016. One of the primary ways it did so was by creating online markets where people who didn't get insurance through work or the government could shop for a health plan from a private insurer. The law offered subsidies for Americans with lower incomes to help pay their premiums and deductibles.

What would happen? The Republican bill is expected to eliminate the subsidies. This would make insurance unaffordable for millions of Americans and sharply reduce the number who buy their own health coverage.

With many fewer people buying coverage, the insurance markets are likely to become increasingly unstable. Many insurers will stop offering policies, and the remaining customers are likely to be sicker than current Obamacare buyers, a reality that will drive up the cost of insurance for everyone who buys it, and force more people out of the markets. The Urban Institute estimates that the change would cause a total of 22.5 million people to lose their health insurance.

What might replace it? Separate legislation may include some new form of subsidy to help people afford insurance. Plans from House Speaker Paul Ryan and the budget committee chairman Tom Price, President-elect Donald J. Trump's pick to lead the Department of Health and Human Services, would both offer a flat tax credit to help buy insurance that varies by age. A proposal from the House Republican Study Committee would give all Americans a standard tax deduction to buy insurance.

2) Obamacare insured millions more by expanding Medicaid.

The health law provided federal funds for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four. Not every state chose to expand, but most did.

What would happen? The Republican plan is expected to eliminate federal funding for the expansion. An estimated 12.9 million people would lose Medicaid coverage, according to the Urban Institute's projections.

What might replace it? Republican leaders have discussed reforming the remaining Medicaid program to give states more autonomy and to reduce future federal investment.

3) Obamacare established consumer protections for health insurance.

One of the law's signature features prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem. The law included a host of other protections for all health plans: a ban on setting a lifetime limit on how much an insurer has to pay to cover someone; a requirement that insurers offer a minimum package of benefits; a guarantee that preventive health services be covered without a co-payment; a cap on insurance company profits; and limits on how much more insurers can charge older people than younger people. The law also required insurance plans to allow adult children to stay on their parents' policies until age 26.

What would happen? These rules can't be changed using the special budget process, so they would stay in place for now. But eliminating some of the other provisions, like the subsidies, and leaving the insurance rules could create turmoil in the insurance markets, since sick customers would have a much stronger incentive to stay covered when premiums rise. .

What might replace it? Mr. Trump has said that he'd like to keep the law's policies on pre-existing conditions and family coverage for young adults, but Senate Republicans recently voted against nonbinding resolutions to preserve those measures, suggesting they may be less committed. Some of the other provisions would probably be on the table if there were new legislation. Republicans in Congress would probably eliminate rules that require a minimum package of benefits for all insurance plans and allow states to determine what insurers would have to include. Mr. Trump has said he'd like to encourage the sale of insurance across state lines, a policy likely to make coverage more skimpy but less expensive for many customers. Republicans would also like to expand tax incentives for people to save money for health expenses.

Many of the Republican proposals would also establish so-called high-risk pools, which would provide subsidized insurance options for people with chronic health problems who wouldn't be able to buy insurance without rules forcing insurers to sell them coverage.

4) Obamacare required individuals to have health insurance and companies to offer it to their workers.

To ensure that enough healthy people entered insurance markets, the law included mandates to encourage broader coverage. Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty.

What would happen? The bill is expected to eliminate the mandates. Some experts think that eliminating the individual mandate, in particular, could destabilize insurance markets by reducing incentives for healthy people to buy coverage. The mandate had less of an impact on the employers, which had already been offering coverage.

What might replace it? Some Republican plans would allow insurers to charge much higher rates to customers who allow their coverage to lapse than to those who renew their policies every year. Such a system might provide a different financial incentive for healthy people to stay insured.

5) Obamacare raised taxes related to high incomes, prescription drugs, medical devices and health insurance.

To help pay for the law's coverage expansion, it raised taxes on several players in the health industry and on high-income earners.

What would happen? The G.O.P. package may roll back those tax increases, though there is some disagreement among Republican lawmakers about the deficit impact of such changes.

What might replace it? Republicans have not discussed raising new taxes to replace those in the Affordable Care Act. But some of their plans would limit the tax benefits offered to people who get their health insurance through work. That change would increase tax revenues, but would increase the cost of health insurance for many people who get it through work.

6) Obamacare made major reforms to Medicare payments.

The law cut the annual pay raises Medicare gives hospitals and reduced the fees Medicare pays private insurance companies. It created new incentives for hospitals and doctors to improve quality. It also set up a special office to run experiments in how Medicare pays doctors and hospitals for health care services. Those experiments are now widespread and have begun changing the way medicine is practiced in some places.

What would happen? The new legislation is expected to leave these changes alone, even though many have come under criticism by Republicans in Congress over the years, including from Mr. Price, an orthopedic surgeon. Many of the experiments could be reshaped or eliminated through regulation or through a future budget process.

What might replace it? Republicans in Congress have long talked about even more ambitious changes to Medicare, intended to move more beneficiaries into private insurance coverage. Mr. Trump has said that he does not want to make major changes to Medicare, so it is unclear if such a proposal would move forward.

7) Obamacare made many smaller changes that will probably last.

Obamacare had a range of policies meant to improve health and health care, including requirements that drug companies report payments made to physicians, a provision written by the Iowa senator Chuck Grassley, a Republican; a requirement that chain restaurants publish calorie counts on their menus; and a rule that large employers must provide a space for women to express breast milk.

What would happen? When Republicans talk about repealing Obamacare, they tend to focus on the parts of the law that expanded insurance coverage and regulated health insurance products, not these ancillary parts. That means that portions of the Affordable Care Act that people don't associate with the word "Obamacare" are likely to endure.

Fred C. Dobbs -> Fred C. Dobbs... , January 15, 2017 at 08:42 AM
Perhaps the most horrendous loss
(to Big Healthcare) will be if ~20M
people lose coverage, even if it is
high-deductible 'catastrophic' coverage,
hospitals will lose billions in insurance
reimbursements for 'free care', which had
*much* to do with why/how Massachusetts
got the ball rolling in the first place.
im1dc -> Fred C. Dobbs... , January 15, 2017 at 11:32 AM
Every time I read an article about the Republicans 'Repeal of Obamacare' I remind myself that Trump has not said he would sign Repeal only.

Rather, he repeatedly has said and recently reiterated that he wants Repeal to coincide with Replace, hours, days, not weeks, months, or years.

That sets up an Executive Branch vs Legislative Branch conflict.

One of the party's pledges will have to give to the others, either Trump or the Speaker Ryan House Republican majority and or the Majority Leader McConnell's Republican majority Senate.

Today I'm guessing Trump gets his wish.

But that leads me to ask what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised, repeatedly.

If it is exciting to watch a train wreck then it is exciting to watch this budding and self-inflicted catastrophe develop in Republican controlled D.C., although I would rather not.

DeDude -> im1dc... , January 15, 2017 at 12:49 PM
"what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised"

Yes my guess is that TrumpCare will not be bigger and better. More likely it will be small - like his hands

DeDude -> Fred C. Dobbs... , January 15, 2017 at 01:02 PM
She missed the biggest and most important part. ACA reduced the size of the doughnut hole in Medicare part D. Indeed ObamaCare was going to make the doughnut hole go completely away by 2020. So if we go back to the old Bush part D there will suddenly be a $4000 gap of no coverage for prescription drugs for our seniors. What are the GOPsters going to do about that?
Fred C. Dobbs -> DeDude... , January 15, 2017 at 01:19 PM
Get rich(er), I'd guess.

[Jan 16, 2017] Trump said he will target pharmaceutical companies over drug prices and demand that they negotiate directly with Medicaid and Medicare.

Jan 16, 2017 | economistsview.typepad.com

pgl -> Fred C. Dobbs... , January 16, 2017 at 05:57 AM

If Trump is serious about what he said - expect a real battle with Speaker Ryan.
DeDude -> pgl... , January 16, 2017 at 06:57 AM
That may be exactly what Trump is counting on. Trump is a classic bully, he gets back at people (to make an example and reduce future "resistance"). It would be very difficult for the GOP to fight with Trump publicly in the first year. Question is what his specifics are. He may even be able to get bipartisan support and split the GOP, the way Bush did with his prescription drug plan for seniors.
reason -> DeDude... , January 16, 2017 at 07:35 AM
Trump doesn't do details. Details are for little people.
libezkova -> DeDude... , January 16, 2017 at 07:44 AM
Crushing Speaker Ryan is not bulling per se. This is a great service for the country.

He is definitely out of touch with reality.

Peter K. -> Fred C. Dobbs... , January 16, 2017 at 05:55 AM
"We're going to have insurance for everybody," Mr. Trump said. "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us."

In the interview, Mr. Trump provided no details about how his plan would work or what it would cost. He spoke in the same generalities that he used to describe his health care goals during the campaign - that it would be "great health care" that left people "beautifully covered."

Single payer!

ilsm -> Peter K.... , January 16, 2017 at 06:10 AM
Trump would have to sell it, but in the past he has praised European style single payer, but said it would be a hard sell in the US.

If Nixon could go to China.

MLK would observe "if US can pay to gut the world, it can afford a little for the home front".

Peter K. -> ilsm... , January 16, 2017 at 06:52 AM
"Beautifully covered."

Can't wait!

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
The GOP's strategy for Obamacare? Repeal and run.
http://www.bostonglobe.com/opinion/2017/01/15/gop-strategy-for-aca-repeal-and-run/aCcjrJWQDjx4r4aRxkMCaL/story.html?event=event25 via @BostonGlobe
Elizabeth Warren - January 15, 2017

For eight years, Republicans in Congress have complained about health care in America, heaping most of the blame on President Obama. Meanwhile, they've hung out on the sidelines making doomsday predictions and cheering every stumble, but refusing to lift a finger to actually improve our health care system.

The GOP is about to control the White House, Senate, and House. So what's the first thing on their agenda? Are they working to bring down premiums and deductibles? Are they making fixes to expand the network of doctors and the number of plans people can choose from? Nope. The number one priority for congressional Republicans is repealing the Affordable Care Act and breaking up our health care system while offering zero solutions.

Their strategy? Repeal and run.

Many Massachusetts families are watching this play out, worried about what will happen - including thousands from across the Commonwealth that I joined at Faneuil Hall on Sunday to rally in support of the ACA. Hospitals and insurers are watching too, concerned that repealing the ACA will create chaos in the health insurance market and send costs spiraling out of control.

They are right to worry. Massachusetts has worked for years to provide high-quality, affordable health care for everyone. But there's no magic wand we can wave to simply snap back to our old system if congressional Republicans decide to rip up the Affordable Care Act and run away.

Health care reform in Massachusetts wasn't partisan. Democrats, Republicans, business leaders, hospitals, insurers, doctors, and consumers all came together behind a commitment that every single person in our Commonwealth deserves access to affordable, high-quality care. When Republican Governor Mitt Romney signed Massachusetts health reform into law in 2006, our state took huge strides toward offering universal health care coverage and financial security to millions of Bay State residents.

That law was a major step forward. Today, more than 97 percent of Bay Staters are covered - the highest rate of any state in the country.

But Massachusetts still has a lot to lose if the ACA is repealed. One big reason for our state's health care success is that we took advantage of the new opportunities offered under the ACA. In addition to making care more accessible and efficient, our state expanded Medicaid, using federal funds to help even more people. And we combined federal and state dollars to help reduce the cost of insurance on the Health Connector.

When the ACA passed, Massachusetts already had in place some of the best consumer protections in the nation. But the ACA still made a big difference. It strengthened protections for people in Massachusetts with pre-existing conditions, allowed for free preventive care visits, and - for the first time in our state - banned setting lifetime caps on benefits.

If the ACA is repealed, our health care system would hang in the balance. Half a million people in the Commonwealth would risk losing their coverage. People who now have an iron-clad guarantee that they can't be turned away due to their pre-existing conditions or discriminated against because of their gender could lose that security. Preventive health care, community health centers, and rural hospitals could lose crucial support. In short, the Massachusetts health care law is a big achievement and a national model, but it also depends on the ACA and a strong partnership with the federal government.

If the cost-sharing subsidies provided by the ACA are slashed to zero, Massachusetts will have a tough time keeping down the cost of plans on the Health Connector. The state can't make funds appear out of thin air to help families on the Medicaid expansion if Republicans yank away support. And our ability to address the opioid crisis will be severely hampered if people lose access to health insurance or if the federal funding provided through the Medicaid waiver disappears. Even in states with strong health care systems - states like Massachusetts - the ACA is critical.

The current system isn't perfect - not by a long shot. There are important steps Congress could take to lower deductibles and premiums, to expand the network of doctors people can see on their plans, and to increase the stability and predictability of the market. We should be working together to make health care better all across the country, just like we've tried to do here in Massachusetts.

This doesn't need to be a partisan fight. But if congressional Republicans continue to pursue repeal of the ACA with nothing more than vague assurances that they might - someday - think up a replacement plan, the millions of Americans who believe in guaranteeing people's access to affordable health care will fight back every step of the way.

Repeal and run is for cowards.

pgl -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
"Providing health insurance to everyone in the country is likely to be very costly, a fact that could diminish support from fiscal conservatives."

Herein lies the real issue. Of course we could reduce these costs by ending the doctor cartel, ending the oligopoly power of the health insurance giants, and pushing back on Big Pharma. Alas, Speaker Ryan is not interested in any of these things.

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:01 AM
Rand Paul says he's drafting
a measure to replace Obamacare http://www.bostonglobe.com/news/politics/2017/01/15/rand-paul-says-drafting-measure-replace-obamacare/y6wMEPKjbi1oEkj9TkekSO/story.html?event=event25 via @BostonGlobe
Miles Weiss - Bloomberg - January 15, 2017

Republican Senator Rand Paul said he's drafting legislation for a health-care insurance plan that could replace Obamacare, including a provision to ''legalize'' the sale of inexpensive insurance policies that provide abbreviated coverage.

''That means getting rid of the Obamacare mandates on what you can buy,'' Paul said in an interview on CNN's ''State of the Union'' on Sunday. Obamacare, which Republicans are moving to repeal, requires insurers to cover a number of procedures -- such as preventive care and pregnancy -- that Paul said drives up the cost.

The Kentucky Republican said he'll propose helping people pay for medical bills through tax credits and health savings accounts, which allow users to set aside money tax-free to pay for medical expenses. His bill would allow individuals and small businesses to form associations when buying insurance, giving them more leverage, he said.

''There's no reason why someone with four employees shouldn't be able to join with hundreds and hundreds of other businesses'' to negotiate better prices, Paul said. Becoming part of larger pools would help small companies secure coverage ''that guarantees the issue of the insurance even if you get sick.'' ...

Paul said his legislation is meant to address concern among Democrats and some Republicans that ending Obamacare would also end health-care coverage for many of the 20 million people who acquired insurance under the law. While Republicans move ahead with their plans to eradicate Obamacare, they have yet to outline an alternative.

''It's incredibly important that we do replacement on the same day as we do repeal,'' Paul said on CNN. ''Our goal,'' he added, is to ''give access to the most amount of people at the least amount of cost.''

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 07:28 AM
(I urge that Dr Paul's plan include
guv'mint-supplied snake bite kits
for all. That could save a bundle.)

[Jan 16, 2017] The Biggest Changes Obamacare Made, and Those That May Disappear

Jan 16, 2017 | economistsview.typepad.com
Fred C. Dobbs : January 15, 2017 at 08:37 AM , 2017 at 08:37 AM
The Biggest Changes Obamacare Made, and Those That
May Disappear https://nyti.ms/2itydsr via @UpshotNYT
NYT - Margot Sanger-Katz - January 13, 2017

It looks like the beginning of the end for Obamacare as we know it.

After years of vowing to repeal the Affordable Care Act, as it is formally known, Republican lawmakers in both chambers of Congress have now passed a bill that will make it easier to gut the law.

Because they are using a special budget process, Republicans won't be able to repeal all provisions of the health law. But it seems like a good time to look at the major changes Obamacare brought to health care, which of those changes may now disappear, and what might replace them.

An important note: We still don't know the details of a repeal bill, and passage is not guaranteed. But Republicans passed a similar package in 2015, vetoed by President Obama, that provides a rough template. Republicans have also said they hope to make further changes through additional legislation. We'll provide updates when new legislative language arrives, expected in several weeks.

1) Obamacare insured millions through new insurance markets.

The health law reduced the number of uninsured Americans by an estimated 20 million people from 2010 to 2016. One of the primary ways it did so was by creating online markets where people who didn't get insurance through work or the government could shop for a health plan from a private insurer. The law offered subsidies for Americans with lower incomes to help pay their premiums and deductibles.

What would happen? The Republican bill is expected to eliminate the subsidies. This would make insurance unaffordable for millions of Americans and sharply reduce the number who buy their own health coverage.

With many fewer people buying coverage, the insurance markets are likely to become increasingly unstable. Many insurers will stop offering policies, and the remaining customers are likely to be sicker than current Obamacare buyers, a reality that will drive up the cost of insurance for everyone who buys it, and force more people out of the markets. The Urban Institute estimates that the change would cause a total of 22.5 million people to lose their health insurance.

What might replace it? Separate legislation may include some new form of subsidy to help people afford insurance. Plans from House Speaker Paul Ryan and the budget committee chairman Tom Price, President-elect Donald J. Trump's pick to lead the Department of Health and Human Services, would both offer a flat tax credit to help buy insurance that varies by age. A proposal from the House Republican Study Committee would give all Americans a standard tax deduction to buy insurance.

2) Obamacare insured millions more by expanding Medicaid.

The health law provided federal funds for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four. Not every state chose to expand, but most did.

What would happen? The Republican plan is expected to eliminate federal funding for the expansion. An estimated 12.9 million people would lose Medicaid coverage, according to the Urban Institute's projections.

What might replace it? Republican leaders have discussed reforming the remaining Medicaid program to give states more autonomy and to reduce future federal investment.

3) Obamacare established consumer protections for health insurance.

One of the law's signature features prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem. The law included a host of other protections for all health plans: a ban on setting a lifetime limit on how much an insurer has to pay to cover someone; a requirement that insurers offer a minimum package of benefits; a guarantee that preventive health services be covered without a co-payment; a cap on insurance company profits; and limits on how much more insurers can charge older people than younger people. The law also required insurance plans to allow adult children to stay on their parents' policies until age 26.

What would happen? These rules can't be changed using the special budget process, so they would stay in place for now. But eliminating some of the other provisions, like the subsidies, and leaving the insurance rules could create turmoil in the insurance markets, since sick customers would have a much stronger incentive to stay covered when premiums rise. .

What might replace it? Mr. Trump has said that he'd like to keep the law's policies on pre-existing conditions and family coverage for young adults, but Senate Republicans recently voted against nonbinding resolutions to preserve those measures, suggesting they may be less committed. Some of the other provisions would probably be on the table if there were new legislation. Republicans in Congress would probably eliminate rules that require a minimum package of benefits for all insurance plans and allow states to determine what insurers would have to include. Mr. Trump has said he'd like to encourage the sale of insurance across state lines, a policy likely to make coverage more skimpy but less expensive for many customers. Republicans would also like to expand tax incentives for people to save money for health expenses.

Many of the Republican proposals would also establish so-called high-risk pools, which would provide subsidized insurance options for people with chronic health problems who wouldn't be able to buy insurance without rules forcing insurers to sell them coverage.

4) Obamacare required individuals to have health insurance and companies to offer it to their workers.

To ensure that enough healthy people entered insurance markets, the law included mandates to encourage broader coverage. Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty.

What would happen? The bill is expected to eliminate the mandates. Some experts think that eliminating the individual mandate, in particular, could destabilize insurance markets by reducing incentives for healthy people to buy coverage. The mandate had less of an impact on the employers, which had already been offering coverage.

What might replace it? Some Republican plans would allow insurers to charge much higher rates to customers who allow their coverage to lapse than to those who renew their policies every year. Such a system might provide a different financial incentive for healthy people to stay insured.

5) Obamacare raised taxes related to high incomes, prescription drugs, medical devices and health insurance.

To help pay for the law's coverage expansion, it raised taxes on several players in the health industry and on high-income earners.

What would happen? The G.O.P. package may roll back those tax increases, though there is some disagreement among Republican lawmakers about the deficit impact of such changes.

What might replace it? Republicans have not discussed raising new taxes to replace those in the Affordable Care Act. But some of their plans would limit the tax benefits offered to people who get their health insurance through work. That change would increase tax revenues, but would increase the cost of health insurance for many people who get it through work.

6) Obamacare made major reforms to Medicare payments.

The law cut the annual pay raises Medicare gives hospitals and reduced the fees Medicare pays private insurance companies. It created new incentives for hospitals and doctors to improve quality. It also set up a special office to run experiments in how Medicare pays doctors and hospitals for health care services. Those experiments are now widespread and have begun changing the way medicine is practiced in some places.

What would happen? The new legislation is expected to leave these changes alone, even though many have come under criticism by Republicans in Congress over the years, including from Mr. Price, an orthopedic surgeon. Many of the experiments could be reshaped or eliminated through regulation or through a future budget process.

What might replace it? Republicans in Congress have long talked about even more ambitious changes to Medicare, intended to move more beneficiaries into private insurance coverage. Mr. Trump has said that he does not want to make major changes to Medicare, so it is unclear if such a proposal would move forward.

7) Obamacare made many smaller changes that will probably last.

Obamacare had a range of policies meant to improve health and health care, including requirements that drug companies report payments made to physicians, a provision written by the Iowa senator Chuck Grassley, a Republican; a requirement that chain restaurants publish calorie counts on their menus; and a rule that large employers must provide a space for women to express breast milk.

What would happen? When Republicans talk about repealing Obamacare, they tend to focus on the parts of the law that expanded insurance coverage and regulated health insurance products, not these ancillary parts. That means that portions of the Affordable Care Act that people don't associate with the word "Obamacare" are likely to endure.

Fred C. Dobbs -> Fred C. Dobbs... , January 15, 2017 at 08:42 AM
Perhaps the most horrendous loss
(to Big Healthcare) will be if ~20M
people lose coverage, even if it is
high-deductible 'catastrophic' coverage,
hospitals will lose billions in insurance
reimbursements for 'free care', which had
*much* to do with why/how Massachusetts
got the ball rolling in the first place.
im1dc -> Fred C. Dobbs... , January 15, 2017 at 11:32 AM
Every time I read an article about the Republicans 'Repeal of Obamacare' I remind myself that Trump has not said he would sign Repeal only.

Rather, he repeatedly has said and recently reiterated that he wants Repeal to coincide with Replace, hours, days, not weeks, months, or years.

That sets up an Executive Branch vs Legislative Branch conflict.

One of the party's pledges will have to give to the others, either Trump or the Speaker Ryan House Republican majority and or the Majority Leader McConnell's Republican majority Senate.

Today I'm guessing Trump gets his wish.

But that leads me to ask what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised, repeatedly.

If it is exciting to watch a train wreck then it is exciting to watch this budding and self-inflicted catastrophe develop in Republican controlled D.C., although I would rather not.

DeDude -> im1dc... , January 15, 2017 at 12:49 PM
"what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised"

Yes my guess is that TrumpCare will not be bigger and better. More likely it will be small - like his hands

DeDude -> Fred C. Dobbs... , January 15, 2017 at 01:02 PM
She missed the biggest and most important part. ACA reduced the size of the doughnut hole in Medicare part D. Indeed ObamaCare was going to make the doughnut hole go completely away by 2020. So if we go back to the old Bush part D there will suddenly be a $4000 gap of no coverage for prescription drugs for our seniors. What are the GOPsters going to do about that?
Fred C. Dobbs -> DeDude... , January 15, 2017 at 01:19 PM
Get rich(er), I'd guess.

[Jan 14, 2017] Insurance overhead runs are probably the best argument for single payer

Jan 14, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , -1
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

[Jan 13, 2017] Reducing the cost of healthcare

Jan 13, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , January 13, 2017 at 07:12 AM
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

anne -> Observer... , January 13, 2017 at 07:37 AM
https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html

January 12, 2017

Senate Takes Major Step Toward Repealing Health Care Law
By THOMAS KAPLAN and ROBERT PEAR

In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes....

[Jan 11, 2017] TrumpCare, Pre-Existing Conditions, and Continuous Coverage naked capitalism

Notable quotes:
"... By Lambert Strether of Corrente . ..."
"... 'Do not go without health insurance, because if you get sick, you won't be able to afford any'. ..."
"... why isn't Bernie jumping up and down for Medicare expansion? ..."
Jan 11, 2017 | www.nakedcapitalism.com
By Lambert Strether of Corrente .

Let me begin by summariing (from thi s excellent post by Jane Timm of NBC ) what we might politely call Trump's intellectual journey on health care policy:

As GOP lawmakers begin the process of repealing President Obama's landmark legislation, it's worth taking a look at the eight times Trump has changed his position on Obamacare since announcing his bid for president more than a year and a half ago:

1. Repeal Obamacare. Look to Canada for inspiration.
2. Repeal Obamacare. Cover everybody.
3. Repeal Obamacare, but 'I like the mandate'
4. Repeal Obamacare. Replace it with something.
5. Repeal Obamacare. Not everyone will be covered.
6. I do want to keep parts of it, we might just amend it.
7. Begin to repeal on day one.
8. 'Be careful' - don't take the blame!

Do Trump's views even matter? Some answer no, arguing that Trump will just delegate everything to Mike Pence, Tom Price, and the rest of the Republican nomenklatura . We'll see, but I don't think The Donald sliced through not one but two party establishments like a hot knife through butter with the goal of handing off power to the Mikes and Toms of this world. So Trump's views matter. We just don't know what they are! Interestingly, Zeke Emmanuel met with Trump on health care policy. His reaction : "I found him engaged, curious, and he asked a lot of thoughtful questions and had a lot of opinions, as you might expect." So, whatever the reasons for Trump's shifting positions, I don't see them as random. Or focus-grouped, either. So there's that).zd

That said, Trump does seem to want TrumpCare to cover pre-existing condtions (or at least be seen to). Politically, that's sensible, since pre-existing conditions skew old , and Trump's base is older . Covering pre-existing conditions is also the right thing to do, as Trump himself seems to recognize :

Trump has consistently supported requiring insurers to cover those with pre-existing conditions, a regulation called guaranteed issue. "I would absolutely get rid of Obamacare," Trump said in a February 25 during the Republican primary, but "I want to keep [the provision regarding] pre-existing conditions. It's the modern age, and I think we have to have it."

Code Name D , January 9, 2017 at 6:21 pm

I don't agree. The "free rider" problem distorts the issue of afordabity. Young people do not buy coverage because they can not aford it – regardless of weather they want it or not. Issurance is so expensive its pricing people out of the markets.

So called "continus coverage" is a typical market solution. "Can't aford it? Well we will keep raising rates until you can. If you can aford it, we will keep rasing rates until you can't."

There still are no price controles.

Frank Stain , January 9, 2017 at 2:00 pm

Are people that hate the mandate because it's government coercion really going to like the Continuous Coverage imperative? The mandate is a soft penalty that taxes individuals who fail to be good citizens by getting their health insurance. The imperative of Continuous Coverage says: 'Do not go without health insurance, because if you get sick, you won't be able to afford any'.
This replaces the soft nudge of the mandate with the the very firm stick of inevitable financial ruin and uncurable sickness if you make a mistake and get sick when you didn't expect to. Why is this preferable to a mandate? Because you can still gamble?
A subsidiary point: are junk catastrophic plans going to count for purposes of Continuous Coverage once they ditch community rating? Those plans aren't going to provide anything like the $$ in the system that allow for coverage of pre-ex conditions.

ProNewerDeal , January 9, 2017 at 2:30 pm

"The mandate is a soft penalty that taxes individuals who fail to be good citizens by getting their health insurance"

The mandate is an ATROCIOUS penalty that penalizes people who cannot afford to purchase a crapified health insurance premium, or those that can "afford the premium" but don't have $6K in emergency savings with which to pay the annual deductible – e.g. can NOT afford to actually use the "insurance". Reminder: US personal adult median income is ~$30K, & net wealth is ~$37K, so this would cover a large portion if not a majority of USians that you are poor-shaming by saying "fail to be good citizens".

Frank Stain , January 9, 2017 at 2:49 pm

I was sort-of quoting the elite liberal line, not trying to poor-shame. But surely it makes sense to call a financial penalty 'soft' in comparison to the much harder penalty of financial ruin + incurable sickness if you mess up by gambling you won't get sick, and then you do.

Roger Smith , January 9, 2017 at 2:56 pm

Atrocious indeed. It is a way to divert attention from the real problem and blame the perceived personality faults of random people you do not know. With all the talk of Trump being some variation of fascist, I cannot figure out how people reconcile this mandate (or forced auto insurance mandates).

I have noticed that a lot of the Obama administration's "legacy" or general work was made by fudging numbers and not actually solving any of the problems at hand. Charging people for not buying a service they already could not afford as a way to punish them into making your numbers look good seems to fit the bill.

J , January 9, 2017 at 3:19 pm

The insurance is for 'catastrophic' coverage only. There are many, many scenarios where you could have an MI, stroke, major trauma, cancer, etc. and end up with surgical, hospital, nursing home and rehab costs running into the $1M+ range. The insurance prevents you from complete financial wipeout; it doesn't exist to make your PCP appointments or Lipitor "free" every month.

Second point, we can argue all we want about who's going to pay for healthcare in this country – the individual, the employer, the government, or some combination thereof. Healthcare will be unaffordable to a large degree based on how fat and sick the US population is. It doesn't matter who's paying when the average healthcare consumer is now 50+ years old with a BMI of 30+, has diabetes, hypertension, sleep apnea, asthma, and continues to smoke, eat fast food, not exercise and has no intention to change.

Last point, we do not ration care at the end of life like other countries with single payor systems do. Most of a person's total lifetime cost of care comes in the last 6 months of life. An enormous amount of savings could be achieved by stopping futile care at the end of life. In my experience, hardly any Americans die at home, everyone dies in an ICU on a ventilator, with multiple IV drips running, often on dialysis too. This is insane. We as a society have to find somewhere to draw the line where certain things shouldn't be done – like dialyIng 90 year olds

steven , January 9, 2017 at 6:10 pm

I don't think anyone is addressing frank's point which is:

In what way is creating a penalty, which tells people who cannot maintain consistent coverage that they can be permanently locked out of the market, better than the individual mandate? The brunt of both approaches is borne by the same people and both approaches inflict pain to coerce behavior. The mandate is a penalty that can be removed at any time by buying a subsidized guaranteed issue policy and the ACA had mechanisms in place to make it feasible to get into coverage. Under repeal, If you have a coverage gap you then face much higher premiums or refusal of needed coverage with no mechanism(such as substantial enough subsidies) to ever be able to afford to get back into the market. Saying that this is better because the government isn't forcing you to buy insurance, when no one goes without insurance if they can afford it in the first place, seems rather silly. Pushing these people into high risk pools has been tried numerous times in this country and has never worked out as the costs are always enormous and there is never the public will to subsidize the pools to the extent needed to keep them afloat.

We know perfectly well that the republicans have no intention of providing the level of subsidy that is necessary to get everyone covered because they don't believe that doing without health insurance/health care is a problem that government should be trying to fix.

As for lambert's statement about trump not shaking things up in order to hand power to others:

Trump doesn't care about policy and has no views on how his power should be used other than to aggrandize his own name. He is a dreaming narcissist whose views change 10 times in a day depending on what he thinks is expedient. He is the perfect malleable president for congressional republicans, an amoral blank slate driven only by his vision of himself as benign dictator. There is no way to counter the clear and organized agenda of the republican establishment, that now completely controls congress, unless you have some coherent policy view of your own. Donald Trump is going to rubber stamp the republican party's agenda and then claim that everyone's problems are solved and most of his supporters will be stupid enough to believe all their problems have disappeared because their all powerful proto-fascist daddy figure waved his big d!#k around and said it is so.

KK , January 9, 2017 at 2:07 pm

How clever is the American system, no work, no medicine

Tom , January 9, 2017 at 2:14 pm

Excellent, excellent snapshot of where we stand during this moment of calm before the storm (or rather, this moment between the current storm (ACA disintegration) and the next, bigger storm (ACA replacement).

Waldenpond , January 9, 2017 at 2:40 pm

This was for voteforno6

Here's what I found:

[There is no Constitutional provision explicitly giving the president the power to issue executive orders. Article II, Section 1 ("The executive power shall be vested in a President of the United States of America.") and Article II, Section 3 ("he shall take Care that the Laws be faithfully executed) have been cited as a grant of this power. Even so, presidential executive orders have the legal force of law if made pursuant to an Act of Congress. The authority for such orders can be either inherent or implied. The power is inherent when the executive order is derived from the powers conferred upon the President as commander-in-chief or, in international situations, as head of state; the power is implied when the order represents a reasonable interpretation of the powers expressly granted to the President under the Constitution.]

and

[Only two Presidential executive orders have been overturned by the courts. The first involved a 1952 presidential order issued by President Truman, Executive Order 1034, placing the nation's steel mills under federal control in order to prevent labor strikes from affecting steel production and thus hurting the national economy.[1] The U.S. Supreme Court determined that the Truman Order was unconstitutional because it overstepped the boundary between executive and legislative powers, holding that President's power to issue the order must stem either from an act of Congress or from the Constitution.[2].

The second executive order overturned by a court was issued by President Clinton. Executive Order 12954 prevented the federal government from entering into contracts with organizations that hire replacements for striking employees.[3] The court determined that the Order was regulatory in nature and preempted by the National Labor Relations Act, which guarantees employers the right to hire permanent replacements.[4]]

My understanding is the executive orders are legitimate if congress has not acted. With all the talk of mcr for all, basic income, ubi, unions, outsourcing, taxing the parasite class and guillotines, that movement needed to win or it will be crushed and I imagine the Ds and Rs will quickly rectify this in the next 2 to 4 years so if the wealthy were unfortunate enough to get someone like Sanders who might do something like this, it will be off the table.

grayslady , January 9, 2017 at 3:40 pm

Executive orders mostly work for issues that don't require congressional funding approval. Based on your excellent brief summary, Trump could probably lower the age of Medicare by Executive Order, but then he would have to find a way to pay for it. My memory may be faulty, but I believe that only Congress can impose taxes, not the President, so Trump would still need to propose a method of paying for Medicare-for-all that Congress would approve. Even if he found a way to pay for healthcare that didn't require congressional funding approval, if the funding source was considered to be too outrageous, Congress could impeach him.

ProNewerDeal , January 9, 2017 at 2:42 pm

0bamaBots & H1llaryB0ts spent years trashing Social Democrats/Sanders voters as "unrealistic" "far-left" "fair-dusty" "un-pragmatic".

Perhaps it was psychological projection, because IMHO 0bama & H1llary were un-pragmatic.

Imagine if 0bama earnestly tried to implement MedicareForAll in 2010? 0bama could've stayed sold-out to the other monopolistic industries that own US pols. Even the most strident left 0bama critics like say Glen Ford would have to say, "look, 0bama is a war criminal, has dictator-murdered US citizens without due process, tried to raise the social security age for GenX & younger, pursued the TPP; but 0bama deserves 1 prop for implementing MedicareForAll & saving 45K USians/yr per Harvard Public Health".

But no, 0bama & H1llary insist on staying sold-out to all major BigBiz groups. Fighting even 1 of them ala FD Roosevelt "I welcome their hatred" to investment bank$tas, is excessively pragmatic for these DLC neoliberal Reagan-clone scumbags.

Clive , January 9, 2017 at 3:07 pm

From an insurance industry point of view, certainly in the U.K. market which I doubt is significantly differently to the U.S., insurers hate complex underwriting. They either want scheme-compliant customers or, if those customers turn up and are found to be wide of scheme, they'd simply rather not have them as customers.

If an insurer is forced to take whatever business rolls up at its door, one way of avoiding having to specialist underwriting is to simply use pricing to deter anyone with a functioning brain cell from ever actually buying a policy. In other words, the fact that you genuinely need underwriting is used to whack the premium or the co-pay up. Okay, technically you are not denying coverage but in practice that's exactly what you are doing because most people will (certainly under the ACA) just pay the fine.

What the politicians - who know diddly squat about insurance product design - hadn't counted on though is, as noted though (correctly) above, you still get a death spiral because a lot of just-above-impoverished and slightly to moderately-severe unwell people will still enter the pool because they realize that even expensive (in-effect catastrophe) insurance is still better than pay-as-you-go. What you're going to deter is a mass market of impoverished or just-above-impoverished but slightly unwell (some sort of pre-existing condition which probably won't result in huge claims - a significant proportion of the potential pool will be this class of customer) potential customers who, in bulk, would contribute the vast proportion of your float (the reserves to pay out claims), because they think, usually correctly, they won't make a mega huge claim and are paying money for nothing.

If any changes in U.S. healthcare policy is considered which involves, to some extent, insurance (assuming Single Payer is off he table, which, however lamentable, sounds like reality) then policy makers really must consult with insurance marketing experts. Failure to understand consumer behavior in this industry will result in policy failures - yet again. None of this is new or not throughly understood - travel insurance has a vast trove of market and customer data to determine who chooses to take out medical expenses cover, who doesn't and why they don't (i.e. chose to spin the roulette wheel and risk not having coverage).

All of which makes me think - remind me again what is so wrong with Single Payer?

oho , January 9, 2017 at 3:19 pm

' remind me again what is so wrong with Single Payer?'

Of all the black swans out there--I'd bet that the most likely black swan is Trump expanding Medicare to under-65's in some form.

Seriously. Nixon to China >>> Takes a jingoistic, nationalistic, hotelier w/massive health insurance bills to like the idea of dumping those costs onto the government.

Trump is already on record liking drug re-importation from Canada and sticking it to Big Pharma.

(but again, it's the most likely of unlikely events) and I'm not holding my breath

Carla , January 9, 2017 at 8:53 pm

' remind me again what is so wrong with Single Payer?'

It treats everybody the same, something the 1% absolutely cannot abide.

A decade ago, I was traveling in Italy with a friend. When we were staying in the beautiful walled city of Lucca, he developed an infection in his index finger. We asked at our B&B where he might get treatment and were directed to the ER of a hospital about 2 blocks away. We joined a couple of other people in the waiting room and after about 5 minutes, someone came and took my friend to an examining room. Nobody in the ER spoke English and we had no Italian. About 10 minutes later, my friend emerged with a neatly bandaged finger and a prescription for antibiotic ointment written in Italian. He explained to me that they had lanced the finger, drained the pus, applied a disinfectant, and bandaged him up. When he took his credit card out to pay, they smilingly waved it away. You see in Italy, if you are hurting, you receive care and treatment because you are a human being.

American one-percenters just can't stand that. Apparently it somehow robs them of their specialness.

Thor's Hammer , January 9, 2017 at 11:09 pm

During my first week of employment in Vancouver Canada the financial secretary of the company called me into the office. "Have you received your Care Card yet?

"I'm a f--ing Yank– Don't I have to become a landed immigrant to apply?

"You are in a civilized country now– we don't allow anybody to go without health care."

I filled out a single page form and was immediately covered for all medical expenses including my pre-existing cancer. Administrative cost for universal coverage– a fraction of the bureaucratic overhead doctors face in the US in order to comply with the ACA & Medicare regulations.

During my stay in Canada I never stood in a line waiting to see a doctor or was placed in a room awaiting a fly-by visit by a doctor seeking to maximize his "production" as is often the case in the USA.

grayslady , January 9, 2017 at 3:46 pm

The favorite method of U.S. insurers to avoid paying for true insurance is to eliminate potential service providers. For example, under your Obamacare policy, all forms of contraception are supposed to be covered; but if no gynecologist in your network performs IUD insertions, then, essentially, you are denied coverage. Happens here a lot with surgical specialties, wherein no doctor in a particular network is qualified to perform certain surgeries even though Obamacare allows for coverage.

sj , January 9, 2017 at 8:47 pm

You know, I'm getting rather tired of the argument that Medicare payments are so abysmal. Doctors will leave, boo-hoo, yadda yadda.

Under the system we have now, those potential losses just get shifted to the uninsured. I just had a medical procedure and reviewed the billing from the hospital.

Cost of the procedure: $6600. Write off for insurer: $5564 Payment by me (since I had not met the deductible) $1036. My insurance company paid nothing.

Now, I'm lucky. I have insurance, and I had been stashing money into an FSA account and so I actually had the $1K. But in what world is it okay to penalize those unable to afford insurance by charging them six times as much as they write off for an insurance company. I

The whole healthcare-for-profit business is obscene. It's the "for profit" part that is subsuming the time of doctors and their staffs. Not the "patient care" part.

The so-called doctor exodus is a red herring. If someone becomes a doctor so that they roll in the money, I don't want to be their patient. Let them leave. Maybe we can actually get back to a healer model.

--
Lot's of interesting articles to be found with this search:

https://www.google.com/#q=how+much+time+to+doctors+spend+working+with+insurance+companies
--
I'm not even going into the fact that so often doctors start out so deep in debt they might feel the need to gouge their patients. That a different, if related, issue.

John k , January 9, 2017 at 3:25 pm

Trump's base is 50+. So what if he drops Medicare to 50+? Even somebody 45 would be happier thinking he would be covered in five years. And 50-65 is more in need than 35-50.
Midwest would be happy, and lots of reps from Midwest just trump proposing this would give it a life of its own and make dems look like pikers.

Course, this would someday be expanded, dooming health insurance does trump owe them anything? Didn't that industry donate to her?
Meanwhile, other corps should be happy to get their sickest workers covered always puzzled other industries haven't lobbied for Medicare expansion.

And with talk of changing Obamacare, why isn't Bernie jumping up and down for Medicare expansion?? Do all dems have undying fealty to insurance?

reslez , January 9, 2017 at 3:41 pm

> why isn't Bernie jumping up and down for Medicare expansion?

Clearly Bernie hasn't learned the art of the deal. But I think everyone figured that out after the primary.

As many problems as there are with Medicare I honestly believe expansion is the only way for Trump to square this circle. In addition it's the best solution for the country in the short-term. Think of how many billions of dollars will be saved on administrative overhead alone.

I don't see how Trump or the Republicans can get around Obamacare repeal, it was a core campaign promise. He can drag Congress along with promises of privatizing it in the future. That's a battle I'm willing to fight. Maybe they'll try to privatize it at the same time, though. I think they'd have to preserve a "public option" either way, simply because there are tons of seniors the health insurers won't touch with a 50 foot pole.

MyLessThanPrimeBeef , January 9, 2017 at 4:06 pm

Contrasting with Medicare for all, Medicare from 50+ on is the lesser of 2 evils (the other being keeping the status quo).

In the spirit of 'not letting good be the enemy of perfect,' i am interested and would like to know more if more people are advocating this.

Why should people die because they can't afford healthcare? Why should people go into debt to get treated? This is more important than no college education without free tuition.

Carla , January 9, 2017 at 9:04 pm

I agree. In the spirit of 'not letting the good be the enemy of perfect,' we should only let people 49 and under die because they can't afford healthcare.

Who needs people 49 and under, anyway?

james wordsworth , January 9, 2017 at 7:46 pm

The crazy thing is that Medicare for all has a solid business argument in its favor (although not for the AMA or big pharma, or big insurance). All companies pay similar amounts for coverage per employee (no more time spent wasted with analyzing plans), so a level playing field, while not as good as a field tilted in your favor, is better than one tilted against you. Great for small companies trying to get new employees, Individuals can start their own businesses without having to worry about losing health benefits (or the high costs of small plans). Everything about medicare for all screams economic efficiency (you know, having doctors doctor, not spending 50% of their time arguing with insurance companies).

Of course this all flies in the face of the american mantra of self reliance and that is where a great economic argument gets destroyed by the reality of a messed up culture in a modern world. Self reliance is great, but in an urban modern world, cooperation works better.

ProNewerDeal , January 9, 2017 at 8:16 pm

+1 IIRC 1 of the US auto mfgers explicitly claimed that the factories in Canada were more cost efficient for them, solely due to the health care costs.

It is as if US business leaders are adherents to neoliberal religion, that for-profit businesses will ALWAYS in ALL product/services provide a better product/svc per $ cost than a government or nonprofit private org can.

The same scenario exists with info tech, ppl wil bitch about Microsoft as OS vendor or office suite software vendor, when they could pay for corporate-level support from Ubuntu Linux or LibreOffice. They bitch about getting jacked by Oracle or SAP ERP, when say 10 MNCs could found a nonprofit dedicated to creating industrial/MNC-level ERP software that could be installed on-site or cloud-computing hosted. Etc.

Dr Duh , January 10, 2017 at 1:23 am

My idea, which helps ameliorate but doesn't solve the problem of the uninsured is to incentivize physicians to provide charity care. As it stands, you take significant risk for minimal to no reward.

The uninsured don't pay and Medicaid pays pennies on the dollar compared to private insurance. To make matters worse these are typically the sickest and the unhealthiest patients, i.e., they put off coming in so their disease is often at a crisis point and have bad nutrition, obesity, tobacco addiction and weak social support systems. They are bad outcomes waiting to happen. To cap it off, they are the most likely to sue you, they have stronger economic incentives to do it and have less social trust in physicians.

I know plenty of people (mostly anesthesiologists) who routinely complain about being paid despite being compelled to do all this work and take all this risk (including non-trivial risk to their own health from needle sticks and the like). I think that a big part of the resentment is that they are compelled to provide charity care as a condition of maintaining their privileges at the hospital.

Instead, let physicians write off charity care at their standard rates, i.e., I normally get $903 to come in at midnight and take out someone's ruptured appendix then take care of them in hospital for a week and provide follow up care for 90 days, but if the person is uninsured, I can deduct the $903 from my adjusted gross income as if it were a charitable donation. Further, physicians could be protected from civil liability for charity care. Though they would still be subject to criminal liability for criminal misbehavior and professional sanctions for substandard care, a bad outcome would not lead to a lawsuit.

I think the most important thing is that this would remove the compulsion to work for free. Most physicians and certainly anyone who has started in the past 10 years didn't do it for money. There's far more money and less stress in finance or tech. Most physicians like taking care of people. It's certainly the best part of my day, but being forced to do something sticks in the craw.
While this would certainly push up physician income.

meeps , January 10, 2017 at 2:14 am

Thanks for the extra detail regarding the 'continuous coverage' conditions.

The 18 month contract term reeks of post-ACA era grandfathered plans (my spouse's employer has a 12 month no coverage contract term) which is the very feature that prices us out of it. People who were priced-out under Obamacare are in for another brain-freeze should the incoming administration order up another self-licking ice cream cone.

I'm concerned that Pence will declare that having two X chromosomes is a pre-existing condition, but that's a subject for another post.

Trump seems to have some opportunity to cultivate an image as the 'most beautiful deal-maker ever' if he can deliver an improved Medicare For All plan. Of course, there's a risk that Republicans will crapify it first and then claim they delivered. But that strikes me as equally risky for Trump and the Republicans. Obama should never have staked his name and the reputation of the Democrats on Romneycare. They lost all credibility and the party is going extinct. I have a low opinion of Trump's branding but I suspect he thinks it's just great! It'd be inept beyond measure to sully it with something even worse than Obamacare. I'll refrain from placing odds just now

dejavuagain , January 10, 2017 at 8:48 am

In the old pre-existing conditions day, the other game played by the insurance companies was to challenge insureds for failing to disclose pre-existing conditions to the insurance company. Even if the insured was not aware of the existence of the pre-existing condition, the insurance company would deny coverage. So, in every big claim, the insurance company would simply deny coverage. Good luck.

And, I was the victim once of an insurance company "losing" my check, and cancelling my health insurance. Scary walking around without health insurance for a few months.

[Jan 11, 2017] Obamacare Republican Leaders Trying to Quell Revolting Senators

Notable quotes:
"... as Lambert has pointed out, Trump has even made statements that sound remarkably un-Republican, like copy the Canadians. ..."
Jan 11, 2017 | www.nakedcapitalism.com
At least some Republicans seem mindful of the concept, "If you break it, you own it."

Even though Obamacare polls as having more opponents than supporters (see here and here ), many of the people who have benefitted from the program are strong supporters. In addition, those who have gotten coverage via Medicaid expansion may not realize that the ACA is the reason. And even with a majority of the public typically polling as not liking Obamacare, only 20% are willing to ditch it with no replacement .

So it should not come as surprise to find that the Republicans, finding themselves in the unexpected position of being able to end Obamacare, are in a squabble over what to do about the, um, opportunity. Obamacare repeal was not a Trump priority and as Lambert has pointed out, Trump has even made statements that sound remarkably un-Republican, like copy the Canadians.

But it appears that regardless of what Trump is willing to do regarding Obamacare, he seems cognizant of the risk of creating disarray and being blamed for it a concern he oddly does not have on other issues. It's likely that this caution is purely cynical: that he understands how complicated implementing a replacement or even a stopgap would be, and he does not want Congress spending time on the Republican party bete noire of Obamacare to the detriment of pushing through Trump's priority items, particularly early in his term when he has the best chance to take ground quickly.

And the Republicans are divided enough to potentially forestall quick action. Politico and Bloomberg put different spins on the same story. Politico goes with the party line: GOP leaders vow to plow ahead with Obamacare repeal . The wee problem is that GOP leadership isn't what it is cracked up to be. Remember how Boehner was repeatedly unable to bring the unruly Tea Party faction to heel? And one of the first acts of the incoming House, to gut its own ethics office , turned into a PR disaster and was quickly scuttled. dbk , January 10, 2017 at 6:42 am

as Lambert has pointed out, Trump has even made statements that sound remarkably un-Republican, like copy the Canadians.

I get the impression T is clued in about how popular a "Canadian-style" health care plan could potentially be.

That there are this many R senators in doubt/on the fence about this particular repeal might lend hope to the possibility that there might be divisions re: other issues, including key nominees. Let's hope the D's have their staffs working full-time on who might be willing/inclined to break ranks for particularly problematic nominations.

My personal concerns here are those for AG (someone who has emerged straight out of 1963) and the Dept of Education, but the list is long and opinions may differ about priorities.

Normal , January 10, 2017 at 7:53 am

They need the lobbyists to write the replacement law ASAP. Then they can proceed with reckless abandon.

Kemal Erdogan , January 10, 2017 at 8:53 am

But, the trouble is the obamacare is more or less what lobbyists wanted.

So, no I see a real trouble here. However militant the republicans seem they would not shoot themselves in the foot. My take is that they will claim that they replaced the law with something better while not touching anything meaningful at the core of it for the simple reason that for such a system to work, it must be more or less the same as what obamacare is. Think how M. Romney's plan looks very similar to Obama's.

The fact is the other workable alternatives are far too much to the left for their liking. So once such a low is introduced that even marginally helps the mid-lower classes, they tend to stick, unless the country falls into open dictatorship that is.

Code Name D , January 10, 2017 at 11:33 am

Ding ding ding!!! That's the billion-dollar observation here. Obamacare is Free-market economics at its best. For it to fail would generate an intellectual crisis among neo-liberals and libertarians alike. To repeal the ACA is to admit that free markets don't work.

For the industry, their bottom line is literally – the bottom line. That ACA is failing is already apparent. So, something must be done to stabilize the ACA before it collapses completely, and give single payer advocates even more political clout than they already have. Wait too long, and single payer might -gasp- be placed on the table.

But I am seeing some odd behavior from the Democrats. They seem to be actively pushing the healthcare battle onto the floor. Keep in mind they are convinced the ACA both works and is extremely popular. If they can get Republicans to repeal the ACA, then they win the mid-term elections and retake congress.

Trump may act the buffoon. But his election proves he is smarter than most people suspect. You underestimate Trump at your own peril. Sending out mixed messages is probably Trumps version of his poker face, while at the same time he is able to read his opponents projections as they react to various seemingly random messages. The further the ACA descends on its death-spiral, the more clout he will acquire to compel changes according to his vision.

Art Eclectic , January 10, 2017 at 12:07 pm

Actually, I don't think the Dems think the ACA works an is extremely popular, I think they see the opportunity to nuke the thing and get single payer on the table. With Trump on records as admiring the Canadian system, that provides an opening (real or not) that would simply not be possible with any other political figure in the oval office. Not even HRC could have pushed through single payer against Republican opposition, Obama did the best he could with Romneycare. The only shot at single payer comes in the form of forcing Trump's hand, so they might as well take their shot.

Sound of the Suburbs , January 10, 2017 at 7:59 am

In a globalised world you just have to look around to see how expensive the US healthcare system is.

Check international league tables and copy someone else's cheaper and better system.

It's that easy.

DJG , January 10, 2017 at 8:43 am

President Susan Collins, as Atrios used to refer to her. And here she is again, a wise elder on health care. Sheesh. The flashbacks of her wondrous bipartisanship and moderation are starting to overwhelm me already.

And President John McCain, who has squandered whatever moral authority he may ever have gained from his stay in the Hanoi Hilton, telling us how to deal with Boris and Natasha.

And Ron Johnson, the most clueless man in Wisconsin except for Scott Walker.

They don't have two synapses to rub together among the three of them. Not one of them has a sense of political economy. They mainly react, and not well. They will end up making Trump look like a statesman. And, ironically, they would have taken the same positions with Hillary Clinton.

So Obama and Trump are not transitional or tranformational. We are marking time as the roofing tiles drop off the buildings from neglect.

Eclair , January 10, 2017 at 8:58 am

Colorado, one of the states that fully embraced the ACA, extending Medicare to hundreds of poor and disabled residents (the state's uninsured rate dropped from 15.8% in 2011 to 6.7 percent in 2015), is bracing for impact, according to the Denver Post.

Of course, the state's voters overwhelmingly rejected a proposed health care cooperative that would have provided residents with universal health coverage a la Canada in last November's election.

Thankfully, we can all saunter over to our neighborhood pot store and stock up. Who needs doctors anyway.

marym , January 10, 2017 at 9:11 am

AHIP demands for Obamacare replacement – The first link to TPM shows a screen shot. Haven't found an actual link to an AHIP publication. The second link to NYT has a discussion of some of the items.

http://talkingpointsmemo.com/dc/insurer-trade-group-lists-its-demands-of-republicans-in-obamacare-repeal-fight

http://www.nytimes.com/2016/12/06/business/health-insurers-obamacare-republicans.html

Code Name D , January 10, 2017 at 11:07 am

Hahahah! They only THINK they are working on it. The TPM is your typical corporate boardroom speak. "Seek solutions for this, that, and the other thing. Send the right messages. Reassure the confidence fairy. Don't rock the boat." In other words, they delegate solutions to minions to figure out while they pose for the camera.

marym , January 10, 2017 at 11:29 am

Agreed on your general assessment of TPM, but not sure I understand your comment. The screenshot is presented as a copy of the actual demands from AHIP, the insurance industry. It does use some pseudo-caring-about-"consumers" language, and I'm no expert, but generally these demands seem to say – keep the money coming; don't send us too many poor/sick people; don't make any rules; or at least none that we don't write.

PKMKII , January 10, 2017 at 9:30 am

The dogs chasing the car finally got it, and now they don't know what to do with it.

RUKidding , January 10, 2017 at 10:36 am

It's to laugh, otherwise we'll all cry and/or pound our heads against brick walls.

It's my understanding that CA has used ACA in a useful way that is benefitting citizens who otherwise would be really up the creek with no paddle. So be it.

ACA is what friggin' BigPharma, BigHospital, BigInsurance, et al, wanted. IOW a Republican's wet dream of a "health care" insurance system. But because the Blackity Black black black Kenyan Muslim got the credit for it, rather than RMoney well then it's simply terrible. If RMoney had enacted the exact same thing, the R Team would be extolling it's virtues 24/7/365.

The impact on me, personally, is smallish. I get that it's been a worthless POS for many, but there are the 20 to 30 million who truly benefitted from it. I know some people personally in that category, and I read comments in blogs from others.

Of course, the most draconian of TeaPartiers simply want to repeal ACA and that's the end of it. You're on your own is their Ayn Randian rally cry. Frankly what's always bugged the sh*t out of me is that the R Team wasted the last 8 years endlessly (was it 60 times?) attempting to vote out ACA, but they spent not one iota of a second in devising a replacement. They have zip, zilch, nada, bupkiss to offer. What a worthless group of grifters.

I doubt that Trump gives a stuff what happens to his voters, other than that he probably has a notion that he'll need their fealty and votes in 4 years. Therefore, Trump may try to get something that has some minimum usefulness enacted.

I can't wait. /s

[Jan 06, 2017] Obamacare is basically Romneycare, a Republican plan set up to be an alternative to universal care.

Notable quotes:
"... They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. ..."
"... They spoke anxiously about rising premiums, deductibles, copays and drug costs. ..."
Jan 06, 2017 | economistsview.typepad.com

Chris Lowery said... January 05, 2017 at 06:42 AM And an interesting take on Trump voters' views on healthcare
http://www.nytimes.com/2017/01/05/opinion/the-health-care-plan-trump-voters-really-want.html?ref=opinion

The Health Care Plan Trump Voters Really Want
By DREW ALTMAN•JAN. 5, 2017
This week Republicans in Congress began their effort to repeal and potentially replace the Affordable Care Act. But after listening to working-class supporters of Donald J. Trump - people who are enrolled in the very health care marketplaces created by the law - one comes away feeling that the Washington debate is sadly disconnected from the concerns of working people.

Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs.

The Kaiser Foundation organized six focus groups in the Rust Belt areas - three with Trump voters who are enrolled in the Affordable Care Act marketplaces, and three with Trump voters receiving Medicaid. The sessions, with eight to 10 men and women each, were held in late December in Columbus, Ohio, Grand Rapids, Mich., and New Cumberland, Pa. Though the participants did not agree on everything, they expressed remarkably similar opinions on many health care questions. They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. They trusted Mr. Trump to do the right thing but were quick to say that they didn't really know what he would do, and were worried about what would come next.

They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance - for which they were eligible for subsidies - saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters. One man in Pennsylvania with Type 1 diabetes reported making frequent trips to Eastern Europe to purchase insulin at one-tenth the cost he paid here.

Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act - including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage - several of these Trump voters recoiled, calling such proposals "not insurance at all." One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.

When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called "chaos" if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, "a smart businessman like Trump would let that happen." Some were uninsured before the Affordable Care Act and said they did not want to be uninsured again. Generally, the Trump voters on Medicaid were much more satisfied with their coverage.

There was one thing many said they liked about the pre-Affordable Care Act insurance market: their ability to buy lower-cost plans that fit their needs, even if it meant that less healthy people had to pay more. They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as "un-American."

If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.

Several states are addressing the problem of surprise medical bills. But other steps urged by these Trump voters will be harder to achieve, including controlling drug costs. Republican health reform plans would probably increase deductibles, not lower them. And providing the more generous subsidies for premiums and deductibles that these voters want would require higher taxes, something the Republican Congress seems disinclined to accept.

In general, the focus among congressional Republicans has been on repealing the Affordable Care Act. There has been little discussion of the priorities favored by the Trump voters who spoke to us. But once a Republican replacement plan becomes real, these working-class voters, frustrated with their current coverage, will want to know one thing: how that plan fixes their health insurance problems. And they will not be happy if they are asked to pay even more for their health care.

Drew Altman is president and chief executive of the Henry J. Kaiser Family Foundation.
Reply Thursday, January 05, 2017 at 06:42 AM pgl said in reply to Chris Lowery ... Excellent story. Yesterday Pence and Paul Ryan lied to us. They are basically assuming Trump supporters are really stupid. This says these supporters are smarter than the GOP frauds assume:

But asked about policies found in several Republican plans to replace the Affordable Care Act - including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage - several of these Trump voters recoiled, calling such proposals "not insurance at all." One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept. Reply Thursday, January 05, 2017 at 06:53 AM JohnH said in reply to pgl... The partisan hack opines...oblivious to the fact that people might have good reason to be angry at skyrocketing prices for what used to be known as catastrophic coverage.

Sad that there seems to be no one but Bernie and his supporters to stand for real health care reform. Instead the debate gets left to partisan hacks, who have nobody's interest in mind except the party's. Reply Thursday, January 05, 2017 at 07:42 AM Peter K. said in reply to JohnH... Obamacare is basically Romneycare, a Republican plan set up to be an alternative to universal care.

Know-nothing Republicans hate it because Obama signed it into law.
Reply Thursday, January 05, 2017 at 07:45 AM pgl said in reply to Chris Lowery ... "If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs."

As in reigning in the monopoly power of Big Pharma. We should also reign the doctor cartel. And of course end the oligopoly power of the health insurance sector. Of course Paul Ryan is in the pockets of the latter - so it ain't gonna happen under his "leadership". Reply Thursday, January 05, 2017 at 06:55 AM EMichael said in reply to Chris Lowery ... Now is not the time to ignore what was actually the "real" problem.


" Republicans Hate Obamacare Because _______


I'm not one to defend the worst parts of Obamacare and those who find themselves on the receiving end of the mandate with no subsidies have some genuine complaints, but generally the bit that goes in the blank there is "it was the blah president's signature legislative achievement."

http://www.eschatonblog.com/

And yes those whose incomes are too high for subsidies do have a complaint.

But for the most part, the single most important "problem" with the ACA is that healthcare in the US is incredibly expensive.

One day people will stop attacking the ACA because of something the ACA had absolutely nothing to do with.

I am thinking that will be when it is gone, and people will then be shocked to see that healthcare in the US is very expensive. Reply Thursday, January 05, 2017 at 07:31 AM JF said in reply to EMichael... Yes, it is expense. This results from pricing that is free from any real market balances or alignments. The incentives are all misaligned.

Need to stop using the word, 'cost' so much. It is all about a non-market space where pricing is unfettered.

Normally, the public brings in uniform rules of Commerce to apply here, or the public does the services directly. Alas. Reply Thursday, January 05, 2017 at 09:07 AM Peter K. said in reply to Chris Lowery ... "If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs."

Why don't the Democrats do this?

Progressive neoliberalism.... Reply Thursday, January 05, 2017 at 08:44 AM pgl said... "Michigan's expansion of Medicaid health insurance coverage has boosted the state's economy and budget, and will continue to do so for at least the next five years, according to a new University of Michigan study."

When Mike Pence and Paul Ryan appeared together to declare Obama's medical reforms a complete failure, it is odd that they never mentioned Michigan - which seems to be a success story. Reply Thursday, January 05, 2017 at 06:50 AM

[Nov 07, 2016] The Cigna CEO took home $49 million in total comp last year – and wasn't the highest paid Cigna executive

www.nakedcapitalism.com

Knifecatcher November 7, 2016 at 2:59 pm

Today our HR department revealed the "new and improved" 2017 benefits package… and it's massively crapified. But good news! The "High Deductible Health Plan" is now a "Consumer Driven Health Plan" thanks to our good friends at Cigna, who kindly reminded us that we just haven't been doing our part as active health care consumers to help reduce health care costs. Because the real problem with health care today is obviously branding.

Knifecatcher November 7, 2016 at 3:27 pm

The consultant they brought in to dump this on us actually said "most people spend more time shopping for the best price on shoes than they spend shopping for the most cost-effective health care."

I had the temerity to point out what I've learned from firsthand experience – that there is NO WAY TO KNOW what a provider will charge for a particular procedure beforehand. The response was that they'd follow up with me later. :)

Apropos of nothing, the Cigna CEO took home $49 million in total comp last year – and wasn't the highest paid Cigna executive.

Waldenpond November 7, 2016 at 5:26 pm

Have you seen the commercial where a female basketball player is goofing off for her child in the house… falls and injures herself. Later she's in a sling and grabbing a small trampoline and in response the 'husband' is on the phone. I guess the inference is he's calling the insurance company but I think it makes more sense to be calling for a price check.

The next time you have a compound fracture, remember to stay calm, and get the best price.

Tvc15 November 7, 2016 at 3:28 pm

And my company is offering a new 2017 "benefit"; Critical Illness Insurance to provide financial protection for an illness such as cancer, stroke or heart attack.

Uh, okay, I thought that is why I pay $6,000 / yr for my high deductible medical plan, not including company subsidy, dental or vision.

Maybe they should have asked marketing to help with the branding.

jrs November 7, 2016 at 3:38 pm

I think it's not actually for medical costs in most cases. It's for the cost of say not being able to work due to cancer and so on. Or that's what I've seen out there, obviously I don't know about your particular plan.

Waldenpond November 7, 2016 at 5:33 pm

Check the policy. Some policies are very specific in that they will include specific cancers and exclude others. The additional can cover illnesses not covered by the initial contract, lost wages, support, and unemployment in case your employer fires you. It may apply to Cobra costs in case of job loss so a person can maintain continuity of care.

Knifecatcher November 7, 2016 at 4:03 pm

We got that too, along with a number of other optional programs. My assumption is that once you get past medical, dental, and vision all those other post-tax "benefits" (pre-paid legal, long term care insurance, etc) are just profit centers, and that the provider gives the employer a kickback for allowing them access to a captive customer base – with payments automatically deducted from each paycheck! I don't know that for sure, but it's the only explanation I can see as to why HR pushes those so hard.

[Nov 01, 2016] The private market has rejected the government sponsored private/public partnership

Nov 01, 2016 | economistsview.typepad.com

JohnH : November 01, 2016 at 03:42 PM

The private market has rejected the government sponsored private/public partnership. The government should return the favor and reject the private market, which has shown that it can't deliver, either by itself or in partnership.

Time to bring back the public option...or just nationalize the health insurance cartel.

Reply Tuesday, November 01, 2016 at 03:42 PM

[Oct 29, 2016] The monthly premium you paid in 2016 was $315.62. Beginning January 1, 2017, your monthly premium will change to $520.59 for the coverage plan you have been automatically renewed into

www.nakedcapitalism.com

Pat October 26, 2016 at 3:56 pm

Caught part of the View this morning including their section on the admission from the Administration that premiums are going to increase in double digits some high for the next year. After some defense of it and info about one of the problems of it (including a somewhat dissonant outburst from Clinton's biggest fan Joy Behar about why should health care be for profit) Goldberg went on a rant. After her starting the defense part of it, it was interesting to hear her go on about paying more and more for less and less and never seeing any kind of rebate because she hadn't used the insurance she paid for for over a decade. She has almost realized she has been had.

Joseph Hill October 26, 2016 at 4:49 pm

In my inbox today courtesy of CareFirst Blue Cross Blue Shield:
"Your premium: The monthly premium you paid in 2016 was $315.62. Beginning January 1, 2017,
your monthly premium will change to $520.59 for the coverage plan you have been automatically
renewed into.
Please understand that premium rates are approved by State regulators pursuant to strict federal and
state rules. We deeply regret increases, but these rates realistically reflect the actual costs of providing
care to you and all other individuals who have bought coverage under the ACA. "
65% annual premium increase (and an deductible increase as well). Absolute F**king disaster.

jrs October 26, 2016 at 4:59 pm

They are telling you a way to change it though. The premium rates are approved by State regulators, means the states should push back.

Joseph Hill October 26, 2016 at 5:11 pm

Right. I'll call my lobbyist.

Skip Intro October 27, 2016 at 8:30 am

That's what I call an October Surprise!

[Oct 28, 2016] Neoliberals believes the problem with the ACA lies with deadbeats who refuse to purchase a substandard product despite a government-imposed penalty. Thier solution? Make the government-imposed penalty higher. What comes next?

Oct 28, 2016 | www.nakedcapitalism.com

Waldenpond October 27, 2016 at 2:39 pm

It's not just premiums. Health care penalty to double. http://newyork.cbslocal.com/2016/10/26/obamacare-premiums-penalties/

Societies that keep ramping up law and punishment are a sign of what?

Jim Haygood October 27, 2016 at 2:45 pm

Thank you, 0bama!
Thank you, John Roberts!

MyLessThanPrimeBeef October 27, 2016 at 3:35 pm

I can see the headlines now – the higher the health care penalty and premiums, the bigger Hillary's landslide victory.

Pat October 27, 2016 at 2:59 pm

Funnily enough, I'm pretty damn sure that the eventual response to this is going to be "pound sand". There is lots of information out there about how to derail that penalty.

The real fix is, of course, single payer and a highly regulated health care market. That said, I'm pretty damn sure that if I were to read the fix article I could pick it apart without much problem, and not just because it has taken the obvious solution off the table. And everyone of my 'solutions' would be ignored because they would come from the point of view that the first goal will be to provide HEALTH CARE and the profits of insurance companies, pharma and private medical are the least important part of the equation.

temporal October 27, 2016 at 3:04 pm

According to the IRS, shared responsibility payments will jump to $695 per adult and $347.50 per child, with the family maximum not to exceed $2,085 or 2.5 percent income above the filing threshold. That's up from $325 per adult and $162.50 per child, with a maximum of $975 per family for the 2015 tax year.

According to the IRS, the national average premium for a bronze level healthcare plan on the Obamacare marketplace was $2,484 a year, or $207 per month for individuals, and $12,240 a year, or $1,020 per month for a family of five or more.

The article compares last years ACA bronze cost to this year's penalty. Not quite valid.
The NY ACA website shows current catastrophic coverage to be $5500 a year with a $6500 per person deductible, so two grand looks like a bargain unless you have some sort of serious medical condition. And two grand is probably only a few months worth of groceries so what's not to like?

OIFVet October 27, 2016 at 3:12 pm

It is still cheaper to pay the penalty than to pay large premiums for a plan that covers practically nothing and has a small provider network. From the NYT article, the 0bama administration argues that having worthless insurance is not paying for nothing, because even people with monster deductibles have "protections against catastrophic costs." Did I miss the part where the 0bama administration instituted out of network maximum on out of pocket costs? There are no out of pocket maximums on out of network costs, and given the small and ever shrinking networks, the administration's contention that crappy policies provide people with "protection" is an utter BS. Yet 0bama has the temerity to insist that we ought to be thanking him for this travesty. It is worth noting that many of my acquaintances who were strongly in favor of 0 care have now began to admit that it does not work. But they don't blame 0bama for it, they blame the republicans. Which is part of their justification for voting for Hillary, because apparently she will "fix 0 care". It is driving me nuts, this willful blindness and unwillingness to question democrat orthodoxy.

Pat October 27, 2016 at 3:19 pm

My personal opinion is that until ALL emergency room coverage is covered regardless of network including hospitalization until transfer (at insurance company cost) is medically feasible, these plans are largely useless. Although there could be a good business in emergency medical jewelry that tells paramedics/EMTs the hospital(s) where they can take you and those you most avoid no matter what the circumstances. Especially since those would need to change yearly, if not more often.

OIFVet October 27, 2016 at 3:41 pm

Emergency rooms are half of it. The other problem is that given the small networks, it is quite possible that these networks do not include specialists in particular specialised care that might be needed. Then there is the very high probability that one is operated by an in-network surgeon in an in-network hospital, but the anesthesiologist is out-of-network, as is the post-op nurse. It is not going to be easy for anyone to sort these things out even in case of non-emergency care. This is where the outrage about the increasing high deductibles and huge premium hikes is doing a disservice to the people, beciause I hardly ever see any article that mentions the fact that these increases are accompanied by large shrinkage of provider networks, and then goes on to mention the unlimited out of network costs and links it to the shrinking networks. It is an effing travesty, the whole lot of it.

I am very much incensed on the issue of access to medical care and how 0 care did not improve it one bit for most people. I could easily just lean back and not give a sh!t because I got mine through the VA, so to hell with everyone else. But I can't, my father died for lack of access to care in this "great, exceptional" country of ours. It is a hurt that will never go away, particularly as the democrat party continues to defend this monstrosity and 0bama callously pats himself on the back. Every time he intones "Thanks 0bama" I feel it as a direct affront on our collective dignity and our basic human right to receive healthcare. An effing narcissist and a sociopath is what he is

Tom October 27, 2016 at 4:22 pm

F*ck Yeah!

craazyboy October 27, 2016 at 4:24 pm

Hillary mentioned there were a couple or two thingies with it that needed fixing. Thanks in advance, Hillary!

With prices compounding at 20-40% annually, Hillary better move fast.

JohnnyGL October 27, 2016 at 4:49 pm

Here comes the magic sparkle pony "public option" dressed up to hide the fact that it'll actually be a massive bailout!

The fines/penalties associated with the "individual mandate" are like the duct tape that holds the whole ACA marketplaces together. The duct tape is looking a bit worn.

craazyboy October 27, 2016 at 6:29 pm

Then the provider network gets narrowed down to a few local barbershops.

A friend told me his doctor told him he was "re-focusing" his practice on "corporate accounts", which is apparently what it sounds like, and my buddy had to look for a new doc.

Jim Haygood October 27, 2016 at 3:58 pm

" There could be a good business in emergency medical jewelry … especially since those would need to change yearly, if not more often. "

Your emergency bracelet or necklace needs to be connected to the IoT (Internet of Things).

Then your EMT can just press a button to find out where you're "covered" today.

Thank you, 0bama!

Tom October 27, 2016 at 4:26 pm

Ha! The patient's medical jewelry would sync with the EMT vehicle's nav system:

Nav Voice: "The nearest hospital in your cardiac arrest patient's network is … 20 miles away. Based on your patient's vital signs, the prognosis is not good. Would you like to recalculate your route? The nearest mortuary is … 2 miles away."

tgs October 27, 2016 at 3:30 pm

Lost my full time job and insurance in August of 2015 (along with over a hundred colleagues). I determined that I would pay a penalty of around $300 if I didn't get Obamacare. On the other hand, I would have paid over $800 for a bottom level policy that I would never use for the four final months of 2015.

So, I will be paying the penalty in 2016 unless I manage to find a job that gives me coverage. I have a little over a year until I quality for medicare.

Tom October 27, 2016 at 4:30 pm

Now that's having some skin in the game!

P.S. I emphathize with your plight. I went without insurance for 2 years after my business tanked in 2009 and it is no fun to have to make that decision and live with it.

Katharine October 27, 2016 at 2:46 pm

Here's a howler from the Guardian:

African revolt threatens international criminal court's legitimacy
https://www.theguardian.com/law/2016/oct/27/african-revolt-international-criminal-court-gambia

The US refusal to participate didn't threaten its legitimacy, of course, because it was always supposed to be for other people, but when they start refusing to be judged–well, really! What's the world coming to? Its senses?

JohnnyGL October 27, 2016 at 4:53 pm

tgs and Tom,

Don't think you're missing out on much. Over here, my employer has been dishing out ACA-style, high-deductible plans with hefty co-insurance since WAY back before it was cool.

Even if you have coverage, the Insurers don't actually pay for stuff. My family as a whole has about $10K in bills backlogged and all four of us are perfectly healthy.

I can only imagine what actual, sick people have wracked up.

dk October 27, 2016 at 3:26 pm

… some think that whether they send hundreds of dollars to the I.R.S. or thousands to an insurance company, they are essentially paying something for nothing.

The opportunity to select my own treatments and providers, and negotiate payment? That's not nothing. But having to pay extra for it is quite an insult.

different clue October 27, 2016 at 3:27 pm

Well, when the penalty costs as much or more than the ObamaCare crapsurance itself, then the boycotters can give in and buy the shitsurance. Perhaps the boycotters will have exterminated Obamacare with death spirals by then anyway.

polecat October 27, 2016 at 4:08 pm

perhaps the public should just quit filing their taxes …. en mass !

THAT might send a message !!

dk October 27, 2016 at 4:43 pm

Doesn't work so good for people paying in through their wages, and filing to get a refund.

Sammy Maudlin October 27, 2016 at 4:05 pm

From Jonathan "Stupidity of the American Voter" Gruber's appearance on CNN :

Look, once again, there's no sense of oh it just has to be fixed. The law is working as designed; however, it could work better, and I think probably the most important thing experts would agree on is that we need a larger mandate penalty. We have individuals who are essentially free riding on the system . They're essentially waiting until they get sick and then getting health insurance. The whole idea of this plan which was pioneered in Massachusetts was that the individual mandate penalty would bring those people into the system and have them participate. The penalty right now is probably too low and that's something ideally we would fix.

In other words, he believes the problem with the ACA lies with "deadbeats" who refuse to purchase a substandard product despite a government-imposed penalty. His solution? Make the government-imposed penalty higher. What comes next? Hmm, let's set the wayback machine to November 27, 2013 and see if anyone has any ideas…

Lambert Strether
November 27, 2013 at 1:41 am

Then again, perhaps I wasn't cynical enough. If you don't assume ObamaCare is about health care, a lot falls into place.

Sammy Maudlin
November 27, 2013 at 10:55 am

It's obviously not about "health care." Where's dollar one towards nutrition education? Subsidies for organic farming? Tax breaks towards gym membership and/or the purchase of exercise equipment? Why are health savings accounts being gutted?

Nope, it's about creating a captive market for the health insurance companies consisting of every American citizen. You don't buy health insurance, there will be tax consequences courtesy of your federal government. Currently, those consequences are minimal. However, how long will it be before ACA "deadbeats" (who aren't paying their "shared responsibility" and costing the rest of us!) are in the crosshairs of the government and a media campaign is launched to repeal the ban on criminal liability for non-compliance?

If I were more cynical, it might look like a protection racket to me.

I'm still not that cynical because they are not asking for criminal penalties yet. But I'm getting there.

polecat October 27, 2016 at 5:03 pm

This is exactly the kind of clueless rhetoric that has caused uprisings in the past ….

I was speechless having read that transcript …… I mean …I read that as … "lets BLEED THEM EVEN MORE !!!"

Jim Haygood October 27, 2016 at 5:27 pm

We had to destroy the consumers in order to save them.

jawbone October 27, 2016 at 7:39 pm

All of which comments above indicate that the Dems have firmly joined the "Hurry Up and Die" as set forth by the Repubs.

ObamaCare, while it has been good for some portion of those insured by it, is essentially a Profit Protection Plan for The Bigs.

EmilianoZ October 27, 2016 at 4:43 pm

Is being on Medicaid better than being on 0bamacare?

timbers October 27, 2016 at 2:42 pm

Health Care

From I think the same NYT article:

The I.R.S. says that 8.1 million returns included penalty payments for people who went without insurance in 2014, the first year in which most people were required to have coverage. A preliminary report on the latest tax-filing season, tabulating data through April, said that 5.6 million returns included penalties averaging $442 a return for people uninsured in 2015.

How can any sane person ignore that as a failure warning as are Obama and Clinton?

The same folks who see Iraq, Afghanistan, Libya, Yemen, Somalia, Syria, and Ukraine as not failures also think Obamacare a success. Higher penalties, more subsidies to rich gigantic insurance corporation is what Hillary will fight for. Oh…and more Iraqs, Libyas, Syrias, and Ukraines, too.

MyLessThanPrimeBeef October 27, 2016 at 3:47 pm

Are penalty payments considered taxes?

If so, they are destroying money with this law.

ProNewerDeal October 27, 2016 at 4:06 pm

fw http://www.vox.com/policy-and-politics/2016/10/25/13396118/obamacare-mandate

Marie Antoinette-level out of touch Matthew Yglesias, claims the ACA could be solved by making the Individual Mandate needs to be "much bigger" & "generous special exemptions" should be removed.

Matthew Yglesias, making an attempt at being the Douchiest Bag.

Adult median income is ~29K. 75% of workers live "paycheck to paycheck", their pay barely meets purchase of essentials like housing rent & food. Student loan debt topped $1 Trillion & is the biggest consumer debt, yet many student loan debtors are Type 1 &/or Type 2 Underemployed, adding another extra cost.

People are already getting insulted by paying the Individual Mandate, or the Tax on Time waiting on hold for IRS Customer No-Service to possibly get a form indicating a "generous exemption". But to Yglesias, if the Mandate was "much bigger", that would compel them to purchase ACA.

Yglesias doesn't mention what "much bigger" Mandate Penalty means. Is it double? Is it half of what a Bronze plan premimums is, & what would that be, ~5X the current Mandate Penalty?

Yglesias makes no mention that many ACA policy holders cannot afford to actually use the insurance, due to the high ~$6K deductibles.

Yyglesias makes no mention of having the Nostradamus Jan 2018 & predict calendar 2017 income, despite many jobs becoming increasingly unstable, gig economy'd or otherwise crapified & unpredictable.

Yglesias makes no mention of the heinous Medicad Estate recovery.

Yglesias does at least suggest that his "bigger Penalty" should be accompanied by a "public option" health insurance.

BTW I recall Yglesias fellow dbag, 0bot Lawrence O'Donnell condescendingly smugly claim on msDNC that the "Indivdual Mandate Penalty" is optional. AFAIK, O'Donnell has never apologized or corrected his incorrect claim.

[Oct 27, 2016] Justice has begun to oppose Hospital Mergers because it has been shown to drive up Health Care Costs, when Hospital Systems consolidate and control larger share of the local market medical prices go up

Oct 27, 2016 | economistsview.typepad.com
pgl : , October 26, 2016 at 08:05 AM
Brad and Michael DeLong make a strong case for more vigorous anti-trust enforcement re the health insurance sector:

https://www.project-syndicate.org/commentary/us-health-insurance-mergers-by-j--bradford-delong-and-michael-m--delong-2016-09

Of course a public option would also lead to more vigorous competition. This needs to be on the top of President Clinton's agenda come January 2017. Trump on the other hand thinks we should just get rid of Obamacare and offer "more choices" whatever that means. Of course Trump has no idea what any of this means.

im1dc -> pgl... , -1
The Obama Administration Justice Dept has been asleep until this past year on Medical competition/consolidation.

Justice has begun this past 9 months to oppose Hospital Mergers b/c it has been shown to drive up Health Care Costs, i.e., when Hospital Systems consolidate and control markets medical prices go up.

Justice is opposing the merger of the only two Hospital Systems in my MSA, regardless the merger is still on.

If it goes through there will be one provider which will control health care costs in a 50+ mile radius in East TN and Western Virginia, although they pledge not to, of course.

Competition works, consolidation does not, even in Healthcare. Consolidation makes some people very wealthy and powerful at the expense of everyone else.

[Oct 25, 2016] New York Times Reports on Sharp Slowing of Insurance Costs Under Obamacare

Oct 25, 2016 | economistsview.typepad.com

anne : October 25, 2016 at 05:32 AM

http://cepr.net/blogs/beat-the-press/nyt-reports-on-sharp-slowing-of-insurance-costs-under-obamacare

October 25, 2016

New York Times Reports on Sharp Slowing of Insurance Costs Under Obamacare

Just kidding. Actually, insurance costs have slowed sharply in the years since the Affordable Care Act was passed, but it is unlikely many readers of the NYT would know this. Instead, it has focused on the large increase (not levels) in premium costs for the relatively small segment of the population insured on the exchanges. In keeping with this pattern, it gives us a front page piece * telling readers about the 25 percent average increase in premiums facing people on the exchange this year. There are two points to keep in mind on this issue.

First, the focus on premiums is exclusively on the relatively small segment of the population getting insurance through the exchanges and specifically through the exchanges managed through the federal government. According to the latest numbers, 12.7 million people are now getting insurance through the exchanges ** (roughly 4.0 percent of the total population). This article refers to the premiums being paid by the 9.6 million people insured through the federally managed exchange (3.0 percent of the total population). Many states, such as California, have well run exchanges that have been more successful in keeping cost increases down.

There are two reasons that costs on the exchanges have been rising rapidly. The first is that insurers probably priced their policies too low initially. Even with the increases this year premium prices are still lower than had been expected in 2010 when the law was passed. In fact, there has been a sharp slowing in the pace of health care cost growth in the last six years. While not all of this was due to the ACA, it was undoubtedly a factor in this slowdown. In the years from 1999 to 2010, health care costs per insured person rose at an average annual rate of 5.7 percent. In the years from 2010 to 2015 costs per insured person rose at an average rate of just 2.3 percent.

[Graph]

The other reason that premiums on the exchanges have risen rapidly is that more people are stiill getting insurance through employers than had been expected. The people who get insurance through employers tend to be healthier on average than the population as a whole. The Obama administration expected that more employers would stop providing insurance, sending their workers to get insurance on the exchanges. Since they have continued to provide insurance, the mix of people getting insurance through the exchanges is less healthy than had been expected.

Note that this has nothing to do with the "young invincible" story that had been widely touted in the years leading up to the ACA. The problem is not that healthy young people are not signing up. The problem is simply that healthy people of all ages are getting their insurance elsewhere. The overall percentage of the population getting insured is higher than projected, not lower as the young invincible silliness would imply.

* http://www.nytimes.com/2016/10/25/us/some-health-plan-costs-to-increase-by-an-average-of-25-percent-us-says.html

** https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-04.html

-- Dean Baker

[Oct 25, 2016] Rates Up 22 Percent For Obamacare Plans, But Subsidies Rise, Too

Oct 25, 2016 | economistsview.typepad.com

Fred C. Dobbs -> anne... October 25, 2016 at 09:19 AM

(Just because Robert Pear does a piece
about the problem doesn't mean it's
not a real one.

Would you believe NPR?)

Rates Up 22 Percent For Obamacare Plans, But Subsidies Rise, Too
https://n.pr/2eokAZG

October 24 - All Things Considered - Alison Kodjak

The cost of health insurance under the Affordable Care Act is expected to rise an average of 22 percent in 2017, according to information released by the Obama administration Monday afternoon.

Still, federal subsidies will also rise, meaning that few people are likely to have to pay the full cost after the rate increases to get insurance coverage.

"We think they will ultimately be surprised by the affordability of the premiums, because the tax credits track with the increases in premiums," said Kevin Griffis, assistant secretary for public affairs at the Department of Health and Human Services.

The 22 percent rise reflects the average for all insurance marketplaces, both federal and state-based exchanges for which data are available. For insurance purchased through the federal HealthCare.gov exchange the rise will average 25 percent.

During a media briefing Monday, Griffis said the 2017 rates are roughly at the level the Congressional Budget Office forecast when the law was proposed. "The initial marketplace rates came in below costs," he said. "Many companies set prices that turned out to be too low." ...

(Assuming Clinton is in the White House,
and enough Dems are in Congress next year,
this had better be dealt with pronto.)

EMichael -> Fred C. Dobbs... , October 25, 2016 at 10:26 AM
No, there is a problem, but Pear has no idea what it actually is and spends no time in putting it in perspective.

These increases were certainly expected, as were the decreases expected in the areas that had them. This is a totally unknown insurance pool. There is no experience with these people at all. To make it worse, the first people to sign up were the people who had been denied insurance because of pre existing conditions who really need medical care and could not afford it.

It'll calm down, but people like Pear are not interested in facts at all, and certainly not interested in perspective.

Why don't people like Pear state, "even with these premium increases insurance through the exchanges will be be less expensive than insurance through employers"? Nah, not the right message.

Or how about, "while the percentage increases are high, more than 3/4 of the insured will not have those kind of increases?" Nah, that doesn't sound that bad.

Or how about finding out what the average premium payments are under the exchanges and putting the increases into perspective? Something like, "Most new enrollments were for low premium policies. Phoenix is going to have some of the highest increases, in some cases going up as high as 111%. Last year a 30 year old single with no subsidy paid, at that low premium level, $60 a month in premiums, or $720 a year. Now that will be $120 a month or $1440 a year. Meanwhile that same person, if he had employer provided insurance would have paid an average premium of(between him and his employer) $6435 a year". Nah, that doesn't say what he wants to say.

Course, deductibles are different in all of those cases. Max out of pocket is fixed under the ACA at $7150 per person. So that 30 year old in Phoenix is going to pay a minimum of $1440 a year for his healthcare. If he gets seriously injured or sick he will pay at most, $8590.

Lot of money, no question. But the guy with employer provided insurance is going to pay a minimum of $6435 a year. His deductible will be around $1478 a year and then add in the out of pocket max that varies drastically, with 14% having less than $2000 as the OOP max and 18% having an OOP max of more than $6000.

http://kff.org/report-section/ehbs-2016-summary-of-findings/

You tell me which is cheaper, which you would rather have, especially if you were a healthy 30 year old.

One more thing. The exchange numbers are for 2017, the employer numbers are for 2016.

Charlatans like Pear are no better than the front page of the National Enquirer. He should not be paid attention to for any reason. And he has been doing it for decades.

DeDude -> anne... , October 25, 2016 at 05:55 AM
Just put a public option on each of these exchanges.
anne -> DeDude... , October 25, 2016 at 06:26 AM
Just put a public option on each of these exchanges.

[ Important, though I would argue not a permanent solution:

http://www.pnhp.org/news/2016/february/clintons-%E2%80%98public-option%E2%80%99-is-a-diversion-we-need-single-payer-medicare-for-all

February 25, 2016

Clinton's 'Public Option' is a Diversion: We Need Single Payer, Medicare for All
By Don McCanne, M.D. ]

EMichael -> anne... , October 25, 2016 at 06:50 AM
It is not a diversion, it is part of the process.

A public option would lead to single payer.

Adamski -> EMichael... , October 25, 2016 at 07:15 AM
If Congressional Dems chicken out of single payer due to the power of the insurance and drug lobbies, then the same lobbies will oppose a public option as they did when the ACA was being debated. Either policy needs the determination to defeat those lobbies, so the same Dems might as well pass single payer. That's why a public option is both a diversion and unlikely to pass.

When the ACA was going through, a public option didn't need 60 votes in the Senate, because they were doing it by reconciliation so it only needed 51. So they whipped against a public option!

EMichael -> Adamski... , October 25, 2016 at 07:23 AM
As bad and uninformed as your entire post is, this takes the cake:


"When the ACA was going through, a public option didn't need 60 votes in the Senate, because they were doing it by reconciliation so it only needed 51. So they whipped against a public option!"

That comment has no basis in reality. You really should not talk with such certainty(even using an exclamation mark)on a subject that you surely have no knowledge.

JohnH -> Adamski... , October 25, 2016 at 07:37 AM
Agreed...EMichael always tries to find a way to let corrupt Democrats off the hook. Democrats have become past masters at explaining away their ineptitude in 2009. Fact is, they really didn't have any intention of accomplishing much for the American people, and their big majority put them in an embarrassing situation that exposed their 'liberal' agenda as being little more than hot air.

More troubling yet...if Democrats couldn't pass a public option with 60 votes in their Senate caucus, how will Hillary be able to pass any positive health care reforms with a bare majority in the Senate...if she even gets that? Overall Democrats will be happy, because they will have a plausible explanation for doing nothing...

pgl -> JohnH... , October 25, 2016 at 07:57 AM
Getting the facts right is letting corruption off the hook? I would say you've lost your mind but me thinks you never found it in the first place.
Dan Kervick said in reply to Adamski... , October 25, 2016 at 07:57 AM
Both would be very difficult to pass. But single payer would be much more difficult, by many orders of political magnitude, since it involved putting the entire private health insurance industry out of business; moving many, but not all, of the workers in that industry into the new public health insurance bureaucracy; and creating new jobs for the people dislocated by the transition.

Since Clinton has not run as a single payer advocate, and thus will have no popular mandate to pass it, it is difficult to imagine her being able to mobilize the huge political effort that would be needed for such a gargantuan political task, even if she wanted to do this.

At this point, the best that can be hoped for is a public option that is then grown and expanded over time, by steps, into a single payer system.

JohnH -> Dan Kervick... , October 25, 2016 at 09:17 AM
The best way to provide single payer would be to nationalize the health insurance industry, which would not be that hard, since it is rapidly consolidating into an oligopoly consisting of a few big firms. And it wouldn't cost that much either.

But, as your say, that's politically impossible...and we're not supposed to entertain that possibility, even though economists love to entertain themselves with pie in the sky stuff like helicopter money.

pgl -> JohnH... , October 25, 2016 at 09:37 AM
"The best way to provide single payer would be to nationalize the health insurance industry".

This is like saying the best way to drink coffee is to drink coffee. I guess you do not know what single payer means.

Dan Kervick said in reply to pgl... , October 25, 2016 at 09:46 AM
It's clear JohnH means that the industry is first nationalized as is, and then methodically consolidated over some period of time to transform it into a lean and proper single payer system..
Tom aka Rusty said in reply to pgl... , October 25, 2016 at 09:49 AM
Actually, there is a difference.

There could be single payer insurance without nationalizing health care services.

Dan Kervick said in reply to Tom aka Rusty... , October 25, 2016 at 10:21 AM
Sure, I guess there could be a privately run health insurance monopoly. But who is advocating for that?
Dan Kervick said in reply to Dan Kervick... , October 25, 2016 at 10:24 AM
JohnH didn't say anything about nationalizing health care services. He said we could nationalize the health *insurance* industry.
pgl -> Dan Kervick... , October 25, 2016 at 10:39 AM
Again - exactly my point. Someone today actually ate his Wheaties and can read with precision.
Dan Kervick said in reply to pgl... , October 25, 2016 at 10:57 AM
Sorry, I have no idea what your point was.
pgl -> Dan Kervick... , October 25, 2016 at 10:38 AM
No one. Exactly my point. Leave it to Rusty to advocate a private monopoly for health insurance.
Tom aka Rusty said in reply to pgl... , October 25, 2016 at 11:11 AM
Huh?

You apparently do not understand the difference between a government single payer insurance and a government monopoly provider.

Julio -> Dan Kervick... , October 25, 2016 at 09:31 AM
Oh, nonsense. Just give Republicans their wishes. Ability to sell across state lines. Deregulation. Non-enforcement of antitrust.
We'll have a single payer in no time.
Peter K. -> Julio ... , -1
Yggies suggests a combo harsher penalities for the Bernie Bros and Gals with a public option.

http://www.vox.com/policy-and-politics/2016/10/25/13396118/obamacare-mandate

[Oct 25, 2016] The cost of health insurance under the Affordable Care Act is expected to rise an average of 22 percent in 2017

Oct 25, 2016 | n.pr

October 24 - All Things Considered - Alison Kodjak

The cost of health insurance under the Affordable Care Act is expected to rise an average of 22 percent in 2017, according to information released by the Obama administration Monday afternoon.

Still, federal subsidies will also rise, meaning that few people are likely to have to pay the full cost after the rate increases to get insurance coverage.

"We think they will ultimately be surprised by the affordability of the premiums, because the tax credits track with the increases in premiums," said Kevin Griffis, assistant secretary for public affairs at the Department of Health and Human Services.

The 22 percent rise reflects the average for all insurance marketplaces, both federal and state-based exchanges for which data are available. For insurance purchased through the federal HealthCare.gov exchange the rise will average 25 percent.

During a media briefing Monday, Griffis said the 2017 rates are roughly at the level the Congressional Budget Office forecast when the law was proposed. "The initial marketplace rates came in below costs," he said. "Many companies set prices that turned out to be too low." ...

(Assuming Clinton is in the White House,
and enough Dems are in Congress next year,
this had better be dealt with pronto.) Reply Tuesday, October 25, 2016 at 09:19 AM EMichael said in reply to Fred C. Dobbs... No, there is a problem, but Pear has no idea what it actually is and spends no time in putting it in perspective.

These increases were certainly expected, as were the decreases expected in the areas that had them. This is a totally unknown insurance pool. There is no experience with these people at all. To make it worse, the first people to sign up were the people who had been denied insurance because of pre existing conditions who really need medical care and could not afford it.

It'll calm down, but people like Pear are not interested in facts at all, and certainly not interested in perspective.

Why don't people like Pear state, "even with these premium increases insurance through the exchanges will be be less expensive than insurance through employers"? Nah, not the right message.

Or how about, "while the percentage increases are high, more than 3/4 of the insured will not have those kind of increases?" Nah, that doesn't sound that bad.

Or how about finding out what the average premium payments are under the exchanges and putting the increases into perspective? Something like, "Most new enrollments were for low premium policies. Phoenix is going to have some of the highest increases, in some cases going up as high as 111%. Last year a 30 year old single with no subsidy paid, at that low premium level, $60 a month in premiums, or $720 a year. Now that will be $120 a month or $1440 a year. Meanwhile that same person, if he had employer provided insurance would have paid an average premium of(between him and his employer) $6435 a year". Nah, that doesn't say what he wants to say.

Course, deductibles are different in all of those cases. Max out of pocket is fixed under the ACA at $7150 per person. So that 30 year old in Phoenix is going to pay a minimum of $1440 a year for his healthcare. If he gets seriously injured or sick he will pay at most, $8590.

Lot of money, no question. But the guy with employer provided insurance is going to pay a minimum of $6435 a year. His deductible will be around $1478 a year and then add in the out of pocket max that varies drastically, with 14% having less than $2000 as the OOP max and 18% having an OOP max of more than $6000.

http://kff.org/report-section/ehbs-2016-summary-of-findings/

You tell me which is cheaper, which you would rather have, especially if you were a healthy 30 year old.

One more thing. The exchange numbers are for 2017, the employer numbers are for 2016.

Charlatans like Pear are no better than the front page of the National Enquirer. He should not be paid attention to for any reason. And he has been doing it for decades. Reply Tuesday, October 25, 2016 at 10:26 AM DeDude said in reply to anne... Just put a public option on each of these exchanges. Reply Tuesday, October 25, 2016 at 05:55 AM anne said in reply to DeDude... Just put a public option on each of these exchanges.

[ Important, though I would argue not a permanent solution:

http://www.pnhp.org/news/2016/february/clintons-%E2%80%98public-option%E2%80%99-is-a-diversion-we-need-single-payer-medicare-for-all

February 25, 2016

Clinton's 'Public Option' is a Diversion: We Need Single Payer, Medicare for All
By Don McCanne, M.D. ] Reply Tuesday, October 25, 2016 at 06:26 AM EMichael said in reply to anne... It is not a diversion, it is part of the process.

A public option would lead to single payer. Reply Tuesday, October 25, 2016 at 06:50 AM Adamski said in reply to EMichael... If Congressional Dems chicken out of single payer due to the power of the insurance and drug lobbies, then the same lobbies will oppose a public option as they did when the ACA was being debated. Either policy needs the determination to defeat those lobbies, so the same Dems might as well pass single payer. That's why a public option is both a diversion and unlikely to pass.

When the ACA was going through, a public option didn't need 60 votes in the Senate, because they were doing it by reconciliation so it only needed 51. So they whipped against a public option! Reply Tuesday, October 25, 2016 at 07:15 AM EMichael said in reply to Adamski... As bad and uninformed as your entire post is, this takes the cake:


"When the ACA was going through, a public option didn't need 60 votes in the Senate, because they were doing it by reconciliation so it only needed 51. So they whipped against a public option!"

That comment has no basis in reality. You really should not talk with such certainty(even using an exclamation mark)on a subject that you surely have no knowledge. Reply Tuesday, October 25, 2016 at 07:23 AM JohnH said in reply to Adamski... Agreed...EMichael always tries to find a way to let corrupt Democrats off the hook. Democrats have become past masters at explaining away their ineptitude in 2009. Fact is, they really didn't have any intention of accomplishing much for the American people, and their big majority put them in an embarrassing situation that exposed their 'liberal' agenda as being little more than hot air.

More troubling yet...if Democrats couldn't pass a public option with 60 votes in their Senate caucus, how will Hillary be able to pass any positive health care reforms with a bare majority in the Senate...if she even gets that? Overall Democrats will be happy, because they will have a plausible explanation for doing nothing... Reply Tuesday, October 25, 2016 at 07:37 AM pgl said in reply to JohnH... Getting the facts right is letting corruption off the hook? I would say you've lost your mind but me thinks you never found it in the first place. Reply Tuesday, October 25, 2016 at 07:57 AM Dan Kervick said in reply to Adamski... Both would be very difficult to pass. But single payer would be much more difficult, by many orders of political magnitude, since it involved putting the entire private health insurance industry out of business; moving many, but not all, of the workers in that industry into the new public health insurance bureaucracy; and creating new jobs for the people dislocated by the transition.

Since Clinton has not run as a single payer advocate, and thus will have no popular mandate to pass it, it is difficult to imagine her being able to mobilize the huge political effort that would be needed for such a gargantuan political task, even if she wanted to do this.

At this point, the best that can be hoped for is a public option that is then grown and expanded over time, by steps, into a single payer system. Reply Tuesday, October 25, 2016 at 07:57 AM JohnH said in reply to Dan Kervick... The best way to provide single payer would be to nationalize the health insurance industry, which would not be that hard, since it is rapidly consolidating into an oligopoly consisting of a few big firms. And it wouldn't cost that much either.

But, as your say, that's politically impossible...and we're not supposed to entertain that possibility, even though economists love to entertain themselves with pie in the sky stuff like helicopter money. Reply Tuesday, October 25, 2016 at 09:17 AM pgl said in reply to JohnH... "The best way to provide single payer would be to nationalize the health insurance industry".

This is like saying the best way to drink coffee is to drink coffee. I guess you do not know what single payer means. Reply Tuesday, October 25, 2016 at 09:37 AM Dan Kervick said in reply to pgl... It's clear JohnH means that the industry is first nationalized as is, and then methodically consolidated over some period of time to transform it into a lean and proper single payer system.. Reply Tuesday, October 25, 2016 at 09:46 AM Tom aka Rusty said in reply to pgl... Actually, there is a difference.

There could be single payer insurance without nationalizing health care services. Reply Tuesday, October 25, 2016 at 09:49 AM Dan Kervick said in reply to Tom aka Rusty... Sure, I guess there could be a privately run health insurance monopoly. But who is advocating for that? Reply Tuesday, October 25, 2016 at 10:21 AM Dan Kervick said in reply to Dan Kervick... JohnH didn't say anything about nationalizing health care services. He said we could nationalize the health *insurance* industry. Reply Tuesday, October 25, 2016 at 10:24 AM pgl said in reply to Dan Kervick... Again - exactly my point. Someone today actually ate his Wheaties and can read with precision. Reply Tuesday, October 25, 2016 at 10:39 AM Dan Kervick said in reply to pgl... Sorry, I have no idea what your point was. Reply Tuesday, October 25, 2016 at 10:57 AM pgl said in reply to Dan Kervick... No one. Exactly my point. Leave it to Rusty to advocate a private monopoly for health insurance. Reply Tuesday, October 25, 2016 at 10:38 AM Tom aka Rusty said in reply to pgl... Huh?

You apparently do not understand the difference between a government single payer insurance and a government monopoly provider. Reply Tuesday, October 25, 2016 at 11:11 AM Julio said in reply to Dan Kervick... Oh, nonsense. Just give Republicans their wishes. Ability to sell across state lines. Deregulation. Non-enforcement of antitrust.
We'll have a single payer in no time. Reply Tuesday, October 25, 2016 at 09:31 AM Peter K. said in reply to Julio ... Yggies suggests a combo harsher penalities for the Bernie Bros and Gals with a public option.

http://www.vox.com/policy-and-politics/2016/10/25/13396118/obamacare-mandate

[Oct 15, 2016] The Breakaway insurance plan amounted to a reverse Ponzi scheme where unsuspecting employers expecting to buy affordable policies instead bought costly reinsurance requiring them to cover each others losses

Notable quotes:
"... Breakaway, with about 300 employees, accused Berkshire and Applied of "siphoning" premiums through a web of illegal shell companies, with diverted premiums going to unlicensed out-of-state insurers, the wire agency said. ..."
"... The plan amounted to a "reverse Ponzi scheme" where unsuspecting employers expecting to buy affordable policies instead bought costly "reinsurance" requiring them to cover each other's losses, leaving taxpayers on the hook for shortfalls when too many workers are injured on the job, Breakaway said. ..."
Oct 15, 2016 | www.nakedcapitalism.com

Cry Shop September 13, 2016 at 1:11 am

Class Warfare:
http://www.ejinsight.com/20160913-buffett-flagship-sued-over-workers-compensation-siphoning/

Breakaway, with about 300 employees, accused Berkshire and Applied of "siphoning" premiums through a web of illegal shell companies, with diverted premiums going to unlicensed out-of-state insurers, the wire agency said.

The plan amounted to a "reverse Ponzi scheme" where unsuspecting employers expecting to buy affordable policies instead bought costly "reinsurance" requiring them to cover each other's losses, leaving taxpayers on the hook for shortfalls when too many workers are injured on the job, Breakaway said.

[Oct 09, 2016] What is Insurance Fraud

Notable quotes:
"... Medical provider knowingly submits false medical bills by billing for services not rendered, billing for wrong procedure codes or billing for procedures of a medical necessity when procedures may have been elective or cosmetic in nature and not covered by health insurance. ..."
Oct 09, 2016 | insurance.ca.gov
Medical Medical

Inflated Billing - Inflated billing by any medical facility, doctor, chiropractor, laboratory, etc.

Healthcare

Billing Fraud - Medical provider knowingly submits false medical bills by billing for services not rendered, billing for wrong procedure codes or billing for procedures of a medical necessity when procedures may have been elective or cosmetic in nature and not covered by health insurance.

[Aug 29, 2016] Audits Of Some Medicare Advantage Plans Reveal Pervasive Overcharging

Aug 29, 2016 | www.npr.org

…The Center for Public Integrity recently obtained, through a Freedom of Information Act lawsuit, the federal audits of 37 Medicare Advantage programs. These audits have never before been made public, and though they reveal overpayments from 2007 - money that has since been paid back - many plans are still appealing the findings.

Medicare Advantage is a privately run alternative to standard Medicare; it has been growing in popularity and now enrolls more than 17 million seniors. In 2014, Medicare paid the health plans more than $160 billion.

But there's growing controversy over the accuracy of billings, which are based on a formula called a risk score; it is designed to pay Medicare Advantage plans higher rates for sicker patients and less for people in good health. In a series of articles published in 2014, the Center for Public Integrity reported that overspending tied to inflated risk scores has cost taxpayers tens of billions of dollars in recent years. …

[Aug 29, 2016] Patriotically, your higher costs of health care are added to America's anemic GDP figures

Notable quotes:
"... New ways to prepare your ramen. Rice in 50 pound sacks. Beans galore. ..."
Aug 29, 2016 | www.nakedcapitalism.com
OpenThePodBayDoorsHAL , August 29, 2016 at 3:50 pm

Ah yes, but think patriotically, your higher costs of health care are added to America's anemic GDP figures, everybody needs to do their bit. Forward Soviet!

RabidGandhi , August 29, 2016 at 3:53 pm

For $1500 you could have flown to Argentina and been treated for free, and still have another $500 left over for Evita t-shirts .

fresno dan , August 29, 2016 at 4:06 pm

allan
August 29, 2016 at 3:33 pm

You have the common, but naive idea that health insurance pays for health related services and/or materials. Yes, that is how it used to be, but actually the medical insurance complex follows the Mickey Mouse (i.e., Disneyland model). This is much more efficient and synergistic at leveraging resources to separate you from all your money.

What is the Disneyland model? Health insurance lets you SEE (and I mean this literally) your doctor, just like a ticket lets you into Disneyland, and you can see all you want.
Now if you want to ride or enter an attraction, or eat something, that is separate.
Now you can see a doctor. Asking him/her a question is a separate charge. The answer is a separate charge. A correct answer requires a specialist…..

cwaltz , August 29, 2016 at 5:14 pm

Isn't it fun?

You get told by the insurance company that it's the hospital/providers fault because of how they coded something and then you get told by the hospital that it's the insurance company's fault.

Meanwhile all you care about is why you are being charged the amount you are being charged and it appears to get more and more complicated as you find yourself charged more than once for a lab or procedure. It's gotten to the point where I've been billed by a doctor for READING a test that they ordered(uh I'm pretty sure there is no point in ordering a test if it isn't going to be read.) That's in addition to now being billed for the lab tech drawing the blood and the lab that has the technicians that read and record the values. And even more maddening, it isn't consistent. Some places bill me for the doctor's time for reading my labs, others do not and good luck figuring out which places are which short of trial and error.

Tom , August 29, 2016 at 7:27 pm

How does it feel to be an unpaid worker in the health insurance industry? I kid, because my wife and I spend a lot of time ourselves straightening out screwed-up bills almost every time one of us sees a doctor. And I mean that. Almost every single time there's an error - either on the doctor's part, the doctor's office staff, the doctor's billing company or the insurer. And god help us if there is a hospital or clinic involved! We are at the point now where we go in knowing the various procedure codes for what we want done and going over them with everybody involved, repeatedly. It helps, although things still get screwed up. Ya gotta love our 'system!'

Bob , August 29, 2016 at 3:32 pm

'We need fundamental changes': US doctors call for universal healthcare
https://www.theguardian.com/us-news/2016/may/05/us-doctors-calling-universal-healthcare-system-affordable-care-act

fresno dan , August 29, 2016 at 4:17 pm

Pat
August 29, 2016 at 2:34 pm

Health Care
UPDATE Here's a handy chart [Wall Street Journal, "Burden of Health-Care Costs Moves to the Middle Class"].

===========================================
I was looking at that, and it seemed it so contradicted all sorts of sources I had read about inflation in items like education as well as health care, energy, food, etcetera. As I have frequently noted, flat screen TV are super cheap, but non edible….unless your very, very hungry.
And than I realized I was reading something into the chart that the chart wasn't addressing at all – it wasn't talking about inflation – it is talking about expenditures.
If medical care is going way up, well than of course other expenditures, especially if salaries are stagnant, HAVE TO GO DOWN.

cwaltz , August 29, 2016 at 5:18 pm

You silly! That's what Care Credit and the rest of the credit vultures are for. They will be more than happy to finance that necessary crown or essential surgery you need.

Left in Wisconsin , August 29, 2016 at 5:48 pm

Yes, that chart is way more shocking than simple inflation. Health care costs are eating the economy. Although I'm sure Krugman will tell us it's because consumer preferences have changed – the middle class apparently just isn't as interested in food or housing as it used to be.

trent , August 29, 2016 at 2:45 pm

with regards to the wall street stating we are only paying more for healthcare

http://menus.nypl.org/menu_pages/24283/explore menu from brooklyn place in 2005-7

https://www.yelp.com/menu/diner-brooklyn current day menu for same place

Look at the price of a burger, eating out is so much more cheaper!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

trent , August 29, 2016 at 2:49 pm

if you're too lazy to click on the links

a cheeseburger from 2005-2007 era was $9.50

now a cheeseburger is $16

nooooooooooooooooooo inflation

John k , August 29, 2016 at 8:22 pm

Go to CA, stop at in-n-out, pay 3.45 for double double, a great burger.
Worth the trip.

nippersmom , August 29, 2016 at 2:50 pm

Actually, they didn't say eating out was cheaper, just that people are spending less of their income on it. I read that as eating out less often or at different types of establishments.

trent , August 29, 2016 at 2:54 pm

haha yes you got me, but i'm still angry about the price of burgers. I'll gladly pay you tuesday for a burger today

MyLessThanPrimeBeef , August 29, 2016 at 4:33 pm

How are you going to compete with energy-efficient, eco-friendly (to ensure a beautiful green world in the future) solar-powered robots when you need to eat cheeseburgers often (or less often)?

Enquiring Mind , August 29, 2016 at 3:00 pm

Income optimization techniques for the modern serf.

New ways to prepare your ramen.
Rice in 50 pound sacks.
Beans galore.

Don't forget your vitamins.

Jeremy Grimm , August 29, 2016 at 3:30 pm

Thanks for reminding me! I need to start up another batch of beans.

But I still buy my rice in 25 pound sacks. I splurge on perfume rice and sometimes I'll have an occasional meal with Korean brown rice although I buy it in 5 pound bags - its a little pricey. Next trip to the store I'll buy a big sack of parboiled rice to make my other rice last longer. I'm still learning how to grow potatoes and I need to build up the soil in my postage stamp garden space.

AnEducatedFool , August 29, 2016 at 4:10 pm

I am a vegetarian on SNAP. I do not know how meat eaters are able to eat a healthy diet on anything less that 750-1000 a month for a family of 3. Even at 1000 a month you are forced to eat a lot of food that is essentially poison.

I recently ran out of my 25 lb Lunderberg brown rice but no one sells that around here. I moved onto quinoa for now. I found a great deal on two 4 lb bags. Once that is gone I'll move onto whatever organic grain is cheapest per serving. I have not seen a lot of organic brown rice recently.

I buy organic beans to avoid Round Up which is used on beans and grains once they are finished growing. Apparently round up decreases the drying time so you get to eat a higher quantity of round up thanks to this process. I avoid it in my house so I only buy organic grains and flours.

If you make your own bread a good food processor makes it an easier and faster process. A few good recipes are found in How to Cook Everything: Vegetarian. My old Kitchen Aid stand mixer is great for ciabatta (Paul Hollywood recipe) but I do not use it all that often now.

If you can afford it buy cedar wood to frame a raised bed that is 3 x 10. 10 ft is ideal since that is the length of electrical conduit to make a quick and easy trellis. 3 feet is ideal because you do not want to step into your bed ever. One of my favorite books on back yard gardening is called Mini Farming: Self Sufficiency on 1/4 acre.

inode_buddha , August 29, 2016 at 5:13 pm

I imagine it depends on where you live: in my part of N.Y. you can eat like a king on 200 a month in food stamps. I know, because I did just that in 2011 or thereabouts. About 25% meat by volume in my diet.

AnEducatedFool , August 29, 2016 at 6:52 pm

200 for a single person is not bad. I spent about that while I was in college while a meat eater and that would work around here for a single person.

3 people make things harder. Due to allergens we need to skip eggs and avoid most conventional food due to stomach issues which I personally lean towards glyphosate causing stomach problems. Avoiding round up is only possible by purchasing organic produce which is primarily frozen for us or out of my garden. We use the dirty dozen and the clean list to purchase produce that is not organic.

A lot of our food needs to be produced by me due to necessity and loaf of organic bread costs between 3.40 and 5.50+ but the price per oz is similar. I make french baguettes and ciabatta bread at least once a week each which brings down food costs as well.

One of the worst moments of the past 6 months was when I had to explain to my son that he could not have cherry tomatoes from the store. I usually tell him know but its rarely over money but we were too low on money at the time and we couldn't justify the expense. He eats about a pint of cherry tomatoes out of my garden per day now.

But the term "eat like a king" needs updating. If you are the king then you can buy local organic produce, grass fed beef, free range chicken/fowl and afford to head out to high end restaurants. That far surpasses 200 a month and is closer to 2000 a month if you actually eat 3 meals a day plus 2 or 3 snacks.

I am outside of Philadelphia.

nippersdad , August 29, 2016 at 7:10 pm

That would depend upon what kind of meat eater you are talking about. Steaks every day or bits of one steak for eight meals over a few months? We buy large chunks of whatever on sale, have it ground up and/or sliced, freeze it and then live on it for years. Literally. We still have most of last year's Thanksgiving turkey ($7.00) frozen in its' own stock, for example. One freezer bag of that should make all the soup we could possibly want to eat, two or three meals worth, and then we freeze what's left for later. You can make a gallon or two of potato soup using little bits of ham and stock for a couple of bucks.

Soups, stews, stir fries, chili; you would be surprised at how far you can make, say, thirty dollars go. If you do the same thing with veggies, buy corn on sale (10 ears for two dollars, say) and cream sacks of it, for example, you can bring down the veggie bill as well. We have gotten to the point where planting a garden is more expensive than just buying the stuff.

And carbs are cheap; rice, potatoes, pasta…as are teabags.

It seems to me that it is largely a matter of time or money. The more time you put into your cooking (making stocks, for example) the less you will ultimately have to spend…..to eat at home, anyway. My habit is to never to make anything that one cannot freeze more than half of, and it seems to work out pretty well.

Carla, August 29, 2016 at 7:38 pm

Educated? For sure. A Fool? Not so much.

One of my favorite ways to turn cold, leftover vegetables into an elegant meal? A generous dollop of curried mayonnaise.

JTMcPhee , August 29, 2016 at 5:37 pm

This is how we get "Chained CPI" shoved in through the back door… http://www.huffingtonpost.com/news/chained-cpi/

[Aug 29, 2016] UN insurance companies as the Department of Denial

www.nakedcapitalism.com
Pat

Looking at that rather stunning graph above, I wonder if all the pundits and so-called experts who keep wondering why the consumer economy is stalled could finally get that it was hijacked by government for the private insurance companies, with a little bit for drug companies and health care providers.

No wait, that would be too sensible, realistic and yes not what they are paid to notice.

Arizona Slim

Private health insurance companies need to go away. Period.

Pat

That would be the logical conclusion of anyone looking at health care as provided, and the costs of providing that health care to the public in other first world countries. The very clear rent extraction that provides little value overall would be rapidly clear.

But unfortunately the people who profit from that…

allan

I just received an Explanation of Benefits [sic] from my insurance, explaining [sic] why they don't want to pay over $1500 in charges from months ago. How much time am I going to spend talking with my provider's front office and the insurance company to try to get this reversed, and who's going to pay me for my time [sic]?

hunkerdown

Worse, who's going to pay your provider for the time? Who's going to pay your insurer to push back at you? You, of course. It's sicker than anything the industry purports to cure.

Roger Smith

They will direct you to their new consumer affairs to voice your concerns.

Best of luck

JTMcPhee

As a nurse, spending hundreds of hours trying to gain authorization for medications and procedures for patients who demonstrably needed and were entitled to them, from the various intermediary and "utilization managment" bits of the private UNsurance thingie, it finally occurred to me that I was being connected to the "Department of Denial," where the cheery or sullen human I finally was able to reach, after persisting and hacking my way through the thorns of the phone tree thicket, would in effect say, "Department of Denial! How may I not help you?"

[Jan 30, 2016] Thoughts on the Cadillac Tax part of the ACA

Notable quotes:
"... Now, suppose we move to single payer. Employer is off the hook for insurance. Will my employer shift that $14k discount to my gross pay and then tax it at the rate necessary to make single payer work (i.e. 40% 10k family)? I doubt it, I think the employer will grab the money (they never gave it to me in the first place). But, this is not a flaw of single payer or the tax required to fund it, its rather my lack of bargaining power with my employer. Under the insurance system, I have virtually no bargaining power with insurers or providers (other than opting out, to which they respond Its your funeral. ). ..."
"... However, you noted that the price of insurance companies pay is not what it costs them. So if they do raise wages, as I believe will happen eventually, it will be at their net cost. In addition, Sanders counts new taxes on that increase of income on employees at the level of what the employees pay insurance companies(without thinking of the tax break) in order to make his numbers make sense(and even with that they dont). ..."
economistsview.typepad.com

EMichael : January 26, 2016 at 09:30 AM

I asked Sarah above what what her thoughts on the Cadillac Tax part of the ACA.

I'd like to have everyone in here(well, not John H) state their opinion on it.

And yes, there is somewhat of a "trap" here. But it is not meant to be mean and/or a "gotcha" kind of thing.

lower middle class said in reply to EMichael...
I vote yes to progressive redistribution with top marginal rate of 40% in excess of 10,400 (27,500 family). Insurers that offer prices below the threshold can use it to compete.
lower middle class said in reply to lower middle class...
How many Health Points do I lose for triggering the trap? Will it affect any of my stats STR, CON, VIT, SPD, INT, END? Is there any loot to add to my pack?
Syaloch -> lower middle class...
You made a successful save vs. Rescission so you're only stunned for six rounds.

When you recover you find that the opened trap contains a Green Lantern of Infinite Griping and a pile of gold coins.

(However upon closer inspection you find that the coins are only novelty Bitcoins and therefore worthless.)

cawley -> EMichael...
I am against the Cadillac tax.

I understand the economic argument but I believe it is just another example of a race to the bottom, especially if it moves people out of plans that cover good utilization into HD plans that put more of the cost on the consumer and discourage good, preventive, early diagnostic utilization.

I would prefer to see measures that strengthen the connection between patients and good primary care.

mulp -> cawley...
In other words, you think Sanders is dead wrong in his claim that better coverage can be provided for 75% or even 50% of the trigger point for the caddy tax? You are arguing that US health care spending is too low.
cawley -> mulp ...
I didn't say any of that.

Costs are too high. Outcomes are not good enough.

I don't know that "Cadillac Plans" are a significant driver of those costs or results. I'm not convinced that driving people out of "Cadillac Plans" will significantly reduce costs, let alone improve outcomes. I think that depends a great deal on the benefit design of the products they wind up in and systemic reform of the delivery network.

So, while I did say that I understand the economic argument, what I didn't say clearly enough is that I have serious reservations about the validity of the economic argument.

Syaloch :
[Class Wars Episode VI: Return of the Occupiers]

http://www.nytimes.com/2011/10/07/opinion/krugman-confronting-the-malefactors.html

Confronting the Malefactors

By Paul Krugman | Oct. 6, 2011

There's something happening here. What it is ain't exactly clear, but we may, at long last, be seeing the rise of a popular movement that, unlike the Tea Party, is angry at the right people.

When the Occupy Wall Street protests began three weeks ago, most news organizations were derisive if they deigned to mention the events at all. For example, nine days into the protests, National Public Radio had provided no coverage whatsoever.

It is, therefore, a testament to the passion of those involved that the protests not only continued but grew, eventually becoming too big to ignore. With unions and a growing number of Democrats now expressing at least qualified support for the protesters, Occupy Wall Street is starting to look like an important event that might even eventually be seen as a turning point.

What can we say about the protests? First things first: The protesters' indictment of Wall Street as a destructive force, economically and politically, is completely right.

A weary cynicism, a belief that justice will never get served, has taken over much of our political debate - and, yes, I myself have sometimes succumbed. In the process, it has been easy to forget just how outrageous the story of our economic woes really is. So, in case you've forgotten, it was a play in three acts.

In the first act, bankers took advantage of deregulation to run wild (and pay themselves princely sums), inflating huge bubbles through reckless lending. In the second act, the bubbles burst - but bankers were bailed out by taxpayers, with remarkably few strings attached, even as ordinary workers continued to suffer the consequences of the bankers' sins. And, in the third act, bankers showed their gratitude by turning on the people who had saved them, throwing their support - and the wealth they still possessed thanks to the bailouts - behind politicians who promised to keep their taxes low and dismantle the mild regulations erected in the aftermath of the crisis.

Now, it's true that some of the protesters are oddly dressed or have silly-sounding slogans, which is inevitable given the open character of the events. But so what? I, at least, am a lot more offended by the sight of exquisitely tailored plutocrats, who owe their continued wealth to government guarantees, whining that President Obama has said mean things about them than I am by the sight of ragtag young people denouncing consumerism.

Bear in mind, too, that experience has made it painfully clear that men in suits not only don't have any monopoly on wisdom, they have very little wisdom to offer. When talking heads on, say, CNBC mock the protesters as unserious, remember how many serious people assured us that there was no housing bubble, that Alan Greenspan was an oracle and that budget deficits would send interest rates soaring.

A better critique of the protests is the absence of specific policy demands. It would probably be helpful if protesters could agree on at least a few main policy changes they would like to see enacted. But we shouldn't make too much of the lack of specifics. It's clear what kinds of things the Occupy Wall Street demonstrators want, and it's really the job of policy intellectuals and politicians to fill in the details.

Rich Yeselson, a veteran organizer and historian of social movements, has suggested that debt relief for working Americans become a central plank of the protests. I'll second that, because such relief, in addition to serving economic justice, could do a lot to help the economy recover. I'd suggest that protesters also demand infrastructure investment - not more tax cuts - to help create jobs. Neither proposal is going to become law in the current political climate, but the whole point of the protests is to change that political climate.

And there are real political opportunities here. Not, of course, for today's Republicans, who instinctively side with those Theodore Roosevelt-dubbed "malefactors of great wealth." Mitt Romney, for example - who, by the way, probably pays less of his income in taxes than many middle-class Americans - was quick to condemn the protests as "class warfare."

But Democrats are being given what amounts to a second chance. The Obama administration squandered a lot of potential good will early on by adopting banker-friendly policies that failed to deliver economic recovery even as bankers repaid the favor by turning on the president. Now, however, Mr. Obama's party has a chance for a do-over. All it has to do is take these protests as seriously as they deserve to be taken.

And if the protests goad some politicians into doing what they should have been doing all along, Occupy Wall Street will have been a smashing success.

Julio -> Syaloch...
Excellent! Thanks for digging this up.
mulp -> Syaloch...
I've never figured out how Krugman and Sanders did not favor responses in 2008-2008-2010 that would not have screwed me a bank customer.

And how can Sanders not be promising to screw me, a bank customer of BofA by four acquisitions that Sanders failed to block by convincing his peers in Congress to prohibit. Now he's promising to force me to get my money from the bank and put it in a new bank and then figure out the dozens or so institutions who need to be told and then checked to change the account number they use to credit or debit. You can't break up big banks without closing a hundred million bank accounts.

Michael :
Democratic socialists don't necessarily believe in state ownership, but democratically means of ownership (e.g. think of worker cooperatives or Mondragon). Bernie has been a strong advocate of worker cooperatives.
http://www.berniesandersvideo.com/3-creating-worker-co-ops.html

Outside of single payer, I have not heard of Bernie advocating government take-over of industries.

But Bernie is doing himself a disservice by using the 'socialist' label. It just creates confusion and not necessarily an accurate label. He is basically a liberal who never took a right turn during the Reagan Revolution.

As you can see, in this speech, Sanders is basically a New Deal liberal.
http://www.motherjones.com/politics/2015/11/bernie-sanders-socialism-speech-georgetown

The revolution Sanders is talking about is about changing hearts and minds, not just about policy. Both Hillary and Sanders will have an uphill battle with a Republican Congress when it comes to enacting policy. However, Sanders is pushing for another Reagan Revolution - influence well beyond policy that he can personally enact.

For example, Obama turned out to be a transformative President on the policy level (healthcare reform, financial reform, civil rights, etc.), but his influence will end once he leave office. Reagan's influence though can still be felt today (Wisconsin, Kansas, every single Republican tax plan, a hatred or distrust of the government, deregulating industries, attacking unions, etc.). Three-four decades we are steal dealing with the Reagan Revolution.

It was a time when "liberal" became a dirty word and people started to run away from it. Instead, people were proud "conservatives", but often in name only. Once you wipe the vague generalities of small government, guns, traditional values, most Americans are liberal, even when it comes to crime and welfare (See Table 1).
http://matthewg.org/ideologicalrepublicans.pdf

One of Bernie's goal is turn the tides and have Americans become more accepting of New Deal liberalism. In way, he is already accomplishing this (for example, today Hillary is a progressive, not a moderate or a Goldwater Girl).

As for electability, Sanders holds up as well, if not better than Hillary in a general match up against Republicans. However, there is more risk/variance associated with Sanders. Hillary is pretty much well-known. People's opinions and views will not change during the general election. There is more risk/variance with Sanders People are still learning about Sanders and working around the confusion of the "socialist" label.

EMichael -> Michael...
"As for electability, Sanders holds up as well, if not better than Hillary in a general match up against Republicans."

Yeah, before he campaigns against Republicans.

Worthless polls until that happens.

Michael -> EMichael...
Worthless projection on your part until (or if it) happens.

If you have an actual point, don't be afraid to make it.

EMichael -> Michael...
I have made it a hundred times in here.

Has Hillary called Sanders a dirty commie?

Of course not.

Ya' think the Reps will not do so?

EMichael :
Well, no answers on the Cadillac Tax and tee time is at 12:30, so I will spell it out.

We have dealt with the "hippy punching" of Sanders by various liberals regarding his healthcare and financial reform platforms. And it seems to me that very little has been said about his healthcare plan, thus my question.

If you opposed the Cadillac Tax, then you should oppose Sanders plan.

https://berniesanders.com/wp-content/uploads/2016/01/Medicare-for-All.pdf

Maybe not totally, but at least in terms of the loss of income the vast majority of insured Americans would see, because it eliminates employer provided insurance when it uses the tax expenditures savings to help pay for his reform(and the numbers still do not work out with that $310 billion).

Now many have been attacked for their commentary on Sanders' plans, yet somehow there has been almost no conversation on what those plans do, and how they do it.

Campaigns are about dreams and goals, but if numbers and details are provided, they should be discussed without the authors of those discussions being attacked.

Julio -> EMichael...
I happen to think that prioritizing the changeover to single payer is a mistake, much like the timing of the ACA was. Too many people are reasonably comfortable with what they have, and we have other, more urgent fights.

Sanders need to focus on the stuff that gets people to the rallies and on the streets. He is doing a good job with inequality. But there is a reason why there was an Occupy Wall Street but no Occupy Blue Cross.

EMichael -> Julio ...
Yep.

But Sanders could not run just on attacking Wall Street and inequality.

lower middle class said in reply to EMichael...
Anecdata below:

My employer claims to spend $19k for family insurance. They sell it to me at a $14k discount and add the discount to my Total Compensation Statement. I don't know the actual price they pay, it may be 100% of what I pay to my employer via pre-tax deductions, or it may be less, who knows.

Now, suppose we move to single payer. Employer is off the hook for insurance. Will my employer shift that $14k discount to my gross pay and then tax it at the rate necessary to make single payer work (i.e. 40% > 10k family)? I doubt it, I think the employer will grab the money (they never gave it to me in the first place). But, this is not a flaw of single payer or the tax required to fund it, it's rather my lack of bargaining power with my employer. Under the insurance system, I have virtually no bargaining power with insurers or providers (other than opting out, to which they respond "It's your funeral.").

Michael -> lower middle class...
It is a strong consensus among economists that the employee bears the burden of payroll taxes and benefits, through lower wages.

Here is a nice graph showing this. The faster healthcare cost rise, the slower wage growth.
http://voices.washingtonpost.com/ezra-klein/2009/10/will_lower_health-care_costs_m.html

If the literature is correct, then moving to a single payer system would increase wages as workers capture some of the previously paid benefits by employers.

Julio -> Michael...
Yes. The question is whether employees will capture those gains.
cawley -> Julio ...
Considering the direction labor share of income has been moving, I think it is a highly dubious proposition that labor will capture a significant portion of reduced employer health care costs in increased wages.

If the labor market were tighter, unions more powerful or regulations more effective, maybe. But not in the current circumstance.

EMichael -> lower middle class...
And I think that compensation is fungible. But Sanders has taken all the cash from employer provided insurance and used it to gain revenue for his plan.

However, you noted that the price of insurance companies pay is not what it costs them. So if they do raise wages, as I believe will happen eventually, it will be at their net cost. In addition, Sanders counts new taxes on that increase of income on employees at the level of what the employees pay insurance companies(without thinking of the tax break) in order to make his numbers make sense(and even with that they don't).

Meanwhile, Obama and the ACA were attacked as killing unions with the Cadillac tax. Yet Sanders' plan is a much more expensive attack on those plans while insuring they receive less health insurance benefits.

Yet, I am missing the attack on Sanders for killing unions.

Strange, huh?

Dan Kervick :
I think the revolution he is talking about is based on the idea that, win or lose, he is going to keep his coalition mobilized and build on it. The goal is a permanent transformation of the American political and ideological landscape, and probably also a drive to recapture the Democratic Party from the "New Democrat" group who took it over in the 90's, and return the party to something more like the more traditional economic left politics exhibited before that takeover.

I think he's going to win; but even if I am wrong, remember that Reagan ran a strong primary campaign in 1976 against Ford before taking over the party in 1980. This move to the left going to happen eventually, because the neoliberal capitalism of 2016 is stagnant, dysfunctional, grossly inegalitarian, oppressive and unpopular. The Clintons represent an old politics that is dying. It might give up the ghost this time, as I think it will, or hang on for one more cycle. But it's not going to last.

I agree that it doesn't make a whole lot of difference whether you call it Democratic Socialism or New Deal Liberalism or something else. Whatever you call it, the program is the broader socialization of health, education and retirement; a "trust-busting" assault on Big Capital, and a variety of moves to empower workers and dramatically compress the income gap.

mulp -> Dan Kervick ...
Sanders was never a Democrat, so he has zero reason to complain about Democrats evolving rightward with voters who bought the free lunch economics of conservatives who shifted Republicans about three times further right.

The conservative policies are free lunch because their tax cuts will never cut the free stuff you expect from government, the getting government out of your life means others won't get a free pass to kill you or harm you or take your stuff, and enforcing morality will never result in your being a rested and convinced for believing in (the wrong) god. Citizen run health care insuranxe means repealing Obamacare so you can cut your rates and increase your benefits (by insuring yourself).

And conservatives have proven TANSTAAFL but even progressives join with conservatives in blaming Democrats and Obama for failed Republican laws.

If Sanders wins the White House with Republicans controlling the House and Senate, my bet is Bernie blames Democrats for failing to pass his laws through Congress.

Dan Kervick -> mulp ...
It has nothing to do with Bernie Sanders or any personal gripes he does or doesn't have the right to have with Democrats. Clearly he is doing so well in Iowa and New Hampshire and elsewhere because millions of *Democrats* prefer the Sanders direction for their party.

I went to a State Democratic Party event here in New Hampshire four or five years ago, where Sanders was the (sole) invited speaker. He didn't crash the gate; he was invited because lots of Democrats love him. The (very big) progressive wing of the Democrats recruited Sanders for this run.

Julio :
With due respect to our host, I'm sick and tired of the "unelectable" argument, especially at this stage in the campaign.

Part of the argument seems to be that if we nominate Sanders, we risk ending up with the eminently electable... Trump! Wasn't he an unelectable joke not so long ago?

lower middle class said in reply to Julio ...
Jeb! leading the Red Team Endorsement Primary. Slytherin - 51 Points!

http://projects.fivethirtyeight.com/2016-endorsement-primary/

Now, look at Clinton's staggering lead. Hufflepuff! (but don't inhale)

lower middle class said in reply to lower middle class...
http://www.theatlantic.com/entertainment/archive/2015/09/hufflepuff-rules/405937/

In Defense of Hufflepuff
The much-maligned house of the Harry Potter series doesn't get nearly enough attention or praise for its egalitarian ethos.

EMichael -> Julio ...
Sarah fen Palin got close to the White House.
Julio :
After reading today's comments, I am more convinced than ever that socio-anarcho-demo-progressivism will not triumph until we sweep demo-anarcho-progressive-socialism to the dustbin of history.
RGC :
Semantics:

democratic socialist vs social democrat

how about

democratic capitalist vs capital democrat

  • capital - the economy is directed by those with the most capital (one dollar=one vote / planning by plutocrats)
  • social - the economy is directed by those able to garner popular support (one person=one vote / planning by bureaucrats)

The reality is that capitalism and socialism are both extremes. If you have government you have a mixed economy. Public vs private is an alternate dichotomy.

Most people who have a lot of money think you should be able to make money from money ( Marx's m -> m'/ Marx thought it should be M-> c -> m') ( c being a product or service). But this eventually arrives at Piketty's dilemma of inequality.

So, to the degree we have capitalism, we should be aware of the danger of m -> m'. IOW, if we don't severely limit the FIRE sector, we will proceed to Dickensian England.

Lafayette :
STAND AND DEFEND

{MT: He has qualified his statements to make it clear that he is a democratic socialist, but that term fails to convey what he really has in mind, or at least I think it does. ...}

Social Democracy is explained here*: http://en.wikipedia.org/wiki/Social_democracy. Succintly, it is the implementation of Social Justice, which is also explained here: http://en.wikipedia.org/wiki/Social_justice

And if that is not enough, let's just say that the principal vector of a Social Democracy is to "level the economic playing field".

How to do it is the key debate. And to my mind, excuse my repetition of the formula employed in this forum. The prime attributes of a Social Democracy, in terms of tangible Public Services are the following:
*Prepare individuals for their roles as both workers and citizens by means of a primary, secondary and tertiary education that is free, gratis and for nothing.
*Institute a National Health Service that covers all citizens of the country at a modest annual cost, and implement it for both curative and preventive purposes.

The rest of what Social Democracy is can be found on the web-site of Congressional Progressive Cause (which presently constitutes 15% of the HofR, and only one Senator - a guy by the name of Bernie Sanders.)

The CPC Progressive Promise that resumés very succinctly its goals can be found here*: http://cpc.grijalva.house.gov/the-progressive-promise/

Now, who thinks all that is just a load of BS ... ?

Lafayette -> Lafayette ...
Frankly, I think that's a pretty good platform to run on. However many elections it takes to teach Americans what Social Democracy really means.

And get a progressive representation in (at least) the HofR to implement progressive legislation.

But, first, we have to make illegal the long-standing election process (since the 1830s) of "gerrymandering". Which is an artificial way of arranging voting districts so that either party "owns the seat".

THEN, AND ONLY THEN, WILL REAL "SOCIAL JUSTICE" BE ALLOWED TO STAND IN THE UNITED STATES.

Bud Meyers :
It doesn't matter if Bernie is a socialist, a democratic socialist, a social democrat, a Marxist or a communist - unless he also had a majority of like-minded people in congress. If your are in doubt about Bernie, you'd only have to fear him as a dictator. Neither Bernie nor Hillary can do much with a GOP dominated congress. At least Bernie moves the Overton window back to the left (true center), whereas the "moderate" Hillary keeps the status quo. Here are two recent posts on this subject.

The Future of the Democratic Party

http://baselinescenario.com/2016/01/26/the-future-of-the-democratic-party/

Hillary Clinton's Lobbyist Fundraisers Want Baby Steps: America Needs a Political Revolution

http://wallstreetonparade.com/2016/01/hillary-clintons-lobbyist-fundraisers-want-baby-steps-america-needs-a-political-revolution/

www.facebook.com/profile.php?id=560338458 :
Universal health insurance, elections that are not bought, the end of the prison state, free college tuition, expanded social security, and a concerted, breaking up the big banks, a clear and practical plan to combat climate change... Surely you can see something socialist in that. The social institutions that have been eviscerated by current establishment politics revitalized.

Incremental won't do it. Impractical is the current trajectory. Revolution means revolution. He cannot get it done alone, that is clear. Doesn't mean we can't get it done together.

[Jan 12, 2016] ObamaCare's Neoliberal Intellectual Foundations Continue to Crumble

Obama is a neoliberal who campaigned as a leftist but has governed as a right-winger.
Notable quotes:
"... By Lambert Strether of Corrente . ..."
"... ObamaCare is a Bad Deal (for Many) ..."
"... they do not comparison shop. ..."
"... very ..."
"... Obama was never in favor of single payer, ever. Wash your mouth out for even suggesting that ..."
"... He had health care lobbyists draft the legislation ..."
"... He's got a history of being a fake leftist going back to his days in Chicago. Obama, Michelle, and Valerie Jarrett were the black faces that legitimated the plan by the Pritzkers and local finance interests to gentrify near South Chicago and push the black community 3 miles further south while giving them nothing. ..."
"... And he's never been a real prof. This constitutional law talk is a crock. No one can remember him teaching any courses (he appears to have taught a couple but made no impression). This was a resume-burnishing post and he did the bare minimum. ..."
"... After he had had told the story of sitting with his dying mother on her death bed, surrounded by paperwork, trying to sort out the restrictions of her employer-based insurance policy and there wasn't a dry eye in the gymnasium, everyone THOUGHT he said, "When I am President, I will fight tooth and nail for single payer for every single American." ..."
"... Nevertheless, as a former Obot who worked tirelessly to get him elected on almost the sole basis of the genuine emotion he exhibited when he told this awful story and how he promised to rectify the situation in the future, I felt the dagger of betrayal when the first thing he said during the health care debate was, "I'm taking single payer of the table." ..."
"... Now, it's the "let's turn everything into a market" game. Don't want to play? Screw you–we'll make it mandatory, and, of course, punitive. This goes way beyond Obamacare into every facet of our lives. Public utilities? Hell no–give them "choice"! Community schools? No way–can't have the races and the classes and the ability levels mixing in such a promiscuous manner–let's go charter "academies", or vouchers. It's a normative takeover under the guise of "rational" "scientific" "efficiency". ..."
"... thatworddoesnotmeanthat ..."
"... Were the architects of RomneyCare (and it's national extension Obamacare) attempting to recreate a golden age, of 11th century free peasants– happily enjoying the abundant commons of medical care, in the carefree forests and dales, before they slipped under the Norman Yoke of feudal exploitation? ..."
"... The record is irrefutable–the ACA was written by the insurance companies with a wink and a nod to Big Pharma and the HMOs. Unless you are going to seriously entertain the notion that these are "communist" institutions, or give a rats ass about anything but making money, you can't really believe what you wrote. You are just angry about something and projecting your fears onto this travesty. ..."
"... As Martin Shkreli put it, he has the perfect "price inelastic" product. Patients are a captive market that's easy to exploit. Either they get what they need or they die. You can charge what you want. ..."
"... Let's not forget why politicians love the sickcare complex. The more an industry turns into a cartel, the easier it is to raise both economic and political rents from it. Let's be honest here and call a spade a spade. Politicians like this system because it easily feeds campaign dollars into the system. It may not be efficient for treating patients, but it's quite efficient for extracting political re ..."
"... It's nearly impossible to "comparison shop" if you're part of an HMO these days. The only choice one really has is to select their PCP. After that the PCP pretty much forces you to see docs and get tests within the hospital system – presumably for "coordinated care". And this for nearly $1000/mo for a single person not receiving much in the way of "healthcare". That which can't continue, won't…. ..."
"... However, for those in that 55-65 age bracket, there is an estate clawback provision that effectively acts as a lien on your estate: once you die your assets will be seized by the state to satisfy all medicaid provided healthcare expenses. ..."
"... When Obama was inaugurated he had more political capital in his pocket than any president in recent memory. The repubs were on the ropes. ..."
"... The United States National Health Care Act, HR 676 ..."
January 12, 2016

By Lambert Strether of Corrente .

ObamaCare is, of course, a neoliberal "market-based" "solution." ObamaCare's intellectual foundations were expressed most clearly in layperson's language by none other than the greatest orator of our time, Obama, himself ( 2013 ):

If you don't have health insurance, then starting on October 1st, private plans will actually compete for your business, and you'll be able to comparison-shop online.There will be a marketplace online, just like you'd buy a flat-screen TV or plane tickets or anything else you're doing online, and you'll be able to buy an insurance package that fits your budget and is right for you.

Let's leave aside the possibility that private plans are phishing for your business, by exploiting informational asymmetries, rather than "competing" for it. Obama gives an operational definition of a functioning market that assumes two things: (1) That health insurance, as a product, is like flat-screen TVs, and (2) as when buying flat-screen TVs, people will comparison shop for health insurance, and that will drive health insurers to compete to satisfy them. As it turns out, scholars have been studying both assumptions, and both assumptions are false. "The dog won't eat the dog food," as marketers say. This will be a short post; we've already seen that the first assumption is false - only 20%-ers who have their insurance purchased for them by an institution could be so foolish as to make it - and a new study shows that the second assumption is false, as well.

ObamaCare's Product Is Not Like a Flat-Screen TV

Here's the key assumptoin that Obama (and most economists) make about heatlth insurance: That it's a commodity, like flat screen TVs, or airline tickets, and that therefore , there exists a "a product that suits your budget and is right for you" because markets. Unfortunately, experience backed up by studies has shown that this is not true. From ObamaCare is a Bad Deal (for Many) . From Mark Pauly, Adam Leive, Scott Harrington, all of the Wharton School, NBER Working Paper No. 21565 ( quoted at NC in October 2015 ):

This paper estimates the change in net (of subsidy) financial burden ("the price of responsibility") and in welfare that would be experienced by a large nationally representative sample of the "non-poor" uninsured if they were to purchase Silver or Bronze plans on the ACA exchanges. The sample is the set of full-year uninsured persons represented in the Current Population Survey for the pre-ACA period with incomes above 138 percent of the federal poverty level. The estimated change in financial burden compares out-of-pocket payments by income stratum in the pre-ACA period with the sum of premiums (net of subsidy) and expected cost sharing (net of subsidy) for benchmark Silver and Bronze plans, under various assumptions about the extent of increased spending associated with obtaining coverage. In addition to changes in the financial burden, our welfare estimates incorporate the value of additional care consumed and the change in risk premiums for changes in exposure to out-of-pocket payments associated with coverage, under various assumptions about risk aversion. We find that the average financial burden will increase for all income levels once insured. Subsidy-eligible persons with incomes below 250 percent of the poverty threshold likely experience welfare improvements that offset the higher financial burden, depending on assumptions about risk aversion and the value of additional consumption of medical care. However, even under the most optimistic assumptions, close to half of the formerly uninsured (especially those with higher incomes) experience both higher financial burden and lower estimated welfare ; indicating a positive "price of responsibility" for complying with the individual mandate. The percentage of the sample with estimated welfare increases is close to matching observed take-up rates by the previously uninsured in the exchanges.

So, for approximately half the "formerly uninsured," ObamaCare is a losing proposition; I don't know what an analogy for flat-screen TVs is; maybe having to send the manufacturer money every time you turn it on, in addition to the money you paid to buy it? That's most definitely not a "package that fits your budget and is right for you," unless you're a masochist or a phool. Second, the portion of those eligible that does the math probably won't buy the product if they're rational actors (and Obamaare needs to double its penetration of the eligible to avoid a death spiral ). That again is not like the market for flat-screen TVs; the magic of the ObamaCare marketplace has not operated to produce a product at every price point (or a substitute).[1] Bad marketplace! Bad! Bad!

Health Care "Consumers" Tend not to Comparison Shop

We turn now to a second NBER study that places even more dynamite at ObamaCare's foundations. From Zarek C. Brot-Goldberg, Amitabh Chandra, Benjamin R. Handel, and Jonathan T. Kolstad, of Berkelely and Harvard, "What Does a Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics" NBER Working Paper No. 21632 ( PDF ), the abstract:

Measuring consumer responsiveness to medical care prices is a central issue in health economics and a key ingredient in the optimal design and regulation of health insurance markets. We study consumer responsiveness to medical care prices, leveraging a natural experiment that occurred at a large self-insured firm which required all of its employees to switch from an insurance plan that provided free health care to a non-linear, high deductible plan[2]. The switch caused a spending reduction between 11.79%-13.80% of total firm-wide health spending. We decompose this spending reduction into the components of (i) consumer price shopping (ii) quantity reductions and (iii) quantity substitutions, finding that spending reductions are entirely due to outright reductions in quantity. We find no evidence of consumers learning to price shop after two years in high-deductible coverage. Consumers reduce quantities across the spectrum of health care services, including potentially valuable care (e.g. preventive services) and potentially wasteful care (e.g. imaging services). We then leverage the unique data environment to study how consumers respond to the complex structure of the high-deductible contract. We find that consumers respond heavily to spot prices at the time of care, and reduce their spending by 42% when under the deductible, conditional on their true expected end-of-year shadow price and their prior year end-of-year marginal price. In the first-year post plan change, 90% of all spending reductions occur in months that consumers began under the deductible, with 49% of all reductions coming for the ex ante sickest half of consumers under the deductible, despite the fact that these consumers have quite low shadow prices. There is no evidence of learning to respond to the true shadow price in the second year post-switch.

So, empirically, these "consumers" just don't act the way that good neoliberal Obama says they should; they do not comparison shop. That alone is enough to undermine the intellectual basis of ObamaCare. If there's no comparison shopping going on, there's no competitive pressure for health insurers to improve their product (assuming good faith, which I don't).

(We can leave aside the issue of motivation, but to speculate, I've found that when I talk to people about health care and health insurance; they're very defensive and proprietary about whatever random solution they've been able to cobble together; and if you'd been sold an exploding flat-screen TV, and had somehow been able to use duct tape and a well-timed fist to the housing to get it work, most of the time, wouldn't you be rather unwilling to go back to the same store and buy another? So there is evidence of "learning"; the lesson learned is once you've got something that seems to works, don't on any account change it, and we "bear those ills we have," rather "than fly to others that we know not of.")

Moreover, the population studied has more ability to comparison shop than ObamaCare's. From page 4 of the study :

Employees at the firm [in the study] are relatively high income ( median income $125,000-$150,000 ), an important fact to keep in mind when interpreting our analysis

The top income for a family of four eligible for ObamaCare is around $95K (and not eligible for subsidy). Do people think this ObamaCare-eligible population has more ability to comparison shop, compared to a population with a $125K median income for individuals, or less ability? To put this more tendentiously, if a population that can afford accountants or at least financial planners doesn't comparison shop, how likely is it that a population that cannot afford those personal services will do so?

Even worse, the population studied reduces costs, not by comparison shopping, but by self-denial of care. From page 6 of the study :

In our setting consumers were provided a comprehensive price shopping tool that allowed them to search for doctors providing particular services by price as well as other features (e.g. location).

So, just like the ObamaCare "marketplace online" front end (at least after they got it working). And what happened?

We find no evidence of price shopping in the first year post switch . The effect is near zero and looks similar for the t -1 - t 0 year pair (moving from pre- to post-change) as it does for earlier year pairs from t 4 to t 1 . Second, we find no evidence of an increase in price shopping in the second year post-switch; consumers are not learning to shop based on price. Third, we find that essentially all spending reductions between t 1 and t 0 are achieved through outright quantity reductions whereby consumers receive less medical care . From t 1 to t 0 consumers reduce service quantities by 17.9%. Fourth, there is limited evidence that consumers substitute across types of procedures (substitution leads to a 2.2% spending reduction from t 1 - t 0 ). Finally, fifth, we find that these quantity reductions persist in the second-year post switch, as the increase in quantities between t 0 and t 1 is only 0.7%, much lower than the pre-period trend in quantity growth. These results occur in the context of consistent (and low) provider price changes over the whole sample period.

Now, it could be that the study population is reducing items like cosmetic surgery and not items like dental care (assuming they've got dental); the Healthcare Economist summary of this study says no. In fact, says the study, some of the foregone services were "likely of high value in terms of health and potential to avoid future costs." And it could be that the lower-income ObamaCare-eligible are smarter shoppers (dubious: Shopping is a tax on time a lot of working people can't pay). That said, it looks like ObamaCare has replaced a system where insurance companies deny people needed care with a system where people deny themselves needed care; which is genius, in a way. However, if any doctors or medical personnel continue to support ObamaCare politically, they should consider closely whether they're violating the principle of non-maleficence - "First, do no harm" - and halt their support, if so. Bad marketplace! Bad, bad!

Conclusion

Shopping for health insurance under ObamaCare is nothing at all like shopping for a flat-screen TV. First, there's a sizeable population who, if they are rational actors, just won't buy health insurance at all; the ObamaCare "marketplace" is not capable of adjusting prices to get such "consumers" to enter the market. Second, people don't comparison shop; they reduce needed care. (To flog the flat-screen TV metaphor even further, if the screen is so defective it's painful to watch, people don't reduce the pain by comparison shopping for a better TV; they reduce the pain by watching less, and keep the TV they have.)

So, with ObamaCare, and thanks to the dogmas of neoliberalism, we have a "marketplace" that repels "consumers" from entering it, and repels people from shopping if they do enter. Perhaps there's a better solution out there?

NOTES

[1] It may be that the ever-increasing mandate penalties will force enough people into the marketplace to make ObamaCare actuarially stable ; needless to say, we don't see Federal agents forcing people into Best Buy to buy TVs, although the social pressure of Black Friday comes close.

[2] Again, much like ObamaCare plans, which are increasingly high-deductible.

Health care , Market inefficiencies on January 12, 2016 by Lambert Strether .

About Lambert Strether

Lambert Strether has been blogging, managing online communities, and doing system administration 24/7 since 2003, in Drupal and WordPress. Besides political economy and the political scene, he blogs about rhetoric, software engineering, permaculture, history, literature, local politics, international travel, food, and fixing stuff around the house. The nom de plume "Lambert Strether" comes from Henry James's The Ambassadors: "Live all you can. It's a mistake not to." You can follow him on Twitter at @lambertstrether. http://www.correntewire.com

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brian t , January 12, 2016 at 3:23 am

The author seems to have forgotten that the kludge called "Obamacare" is not the single payer solution that this Obama wanted. What you have is what was able to get past a Congress after intense lobbying by HMOs and insurers. I see little evidence of ideology in the result, "neoliberal" or otherwise. It does nothing to address the insane-and-rising cost of healthcare, because the vested interests are OK with that.

Yves Smith , January 12, 2016 at 5:12 am

Let me clue you in: the readers here are way WAY too clued in to buy your Big Lie.

1. Obama was never in favor of single payer, ever. Wash your mouth out for even suggesting that

2. He had health care lobbyists draft the legislation

3. He used the "public option" as a bright shiny toy. He was so uncommitted to it he didn't even trade it away. He gave it up as a free concession. A basic principle in negotiating is you NEVER make a free concession. The fact that he just threw it away is proof he never meant it as anything more than a talking point

I hope you are paid to dispense this blather. I really feel sorry for you if you actually believe it. Obama is a neoliberal who campaigned as a leftist but has governed as a right-winger. His apologists have regularly used the meanie Republicans as excuses for his selllouts, when Obama gets what he wants when he wants it, and there's no evidence that his center-right results are at all at odds with what he intended to achieve.

Yves Smith , January 12, 2016 at 4:31 pm

Huh? Obama has proven to be an extremely skilled political infighter when he wants something done. And as to him being center-right, all you have to do is look at his staff, most important his economics team.

He's got a history of being a fake leftist going back to his days in Chicago. Obama, Michelle, and Valerie Jarrett were the black faces that legitimated the plan by the Pritzkers and local finance interests to gentrify near South Chicago and push the black community 3 miles further south while giving them nothing. See here for details:

http://www.nakedcapitalism.com/2012/05/exclusive-how-obamas-early-career-succes-was-built-on-fronting-for-chicago-real-estate-and-finance.html

And he's never been a real prof. This constitutional law talk is a crock. No one can remember him teaching any courses (he appears to have taught a couple but made no impression). This was a resume-burnishing post and he did the bare minimum.

Hayek's Heelbiter , January 12, 2016 at 12:55 pm

Beg to slightly differ regarding Obama and single payer (if the transcripts of his campaign rally speech in Jersey City before he was nominated hadn't been scrubbed from the Internet, I'd have the exact wording).

After he had had told the story of sitting with his dying mother on her death bed, surrounded by paperwork, trying to sort out the restrictions of her employer-based insurance policy and there wasn't a dry eye in the gymnasium, everyone THOUGHT he said, "When I am President, I will fight tooth and nail for single payer for every single American."

And the gymnasium absolutely erupted in applause. Apparently, he said something very CLOSE to that, but when the sentence is carefully parsed, did not mean that all.

Nevertheless, as a former Obot who worked tirelessly to get him elected on almost the sole basis of the genuine emotion he exhibited when he told this awful story and how he promised to rectify the situation in the future, I felt the dagger of betrayal when the first thing he said during the health care debate was, "I'm taking single payer of the table."

Lambert Strether Post author , January 12, 2016 at 1:58 pm

I hate to say this, but a lot of us at Corrente did try to keep track in 2008, and I can't remember any reporting on this at the time, and we were also strongly for single payer, which we also kept track of. Not to say that we couldn't have missed something, but a link to something contemporaneous would be helpful.

Michael Hudson , January 12, 2016 at 2:32 pm

I know that I've said this on NC before, but Yves is absolutely right - and THEN some. When Dennis Kucinich tried to introduce EVEN A DISCUSSION of single payer in Congress, the Democratic Party leadership blocked him from even bringing it up. Pelosi et al. were absolutely committed to the Republican neoliberal policy.

This led us to discuss whether the only way to get progressive health care policy was to start a new party, now that the Democrats have become the Wall Street wing of the Republican Party's natural resource monopolists.

Hayek's Heelbiter , January 12, 2016 at 3:37 pm

If you could locate a transcript, I would dearly love to read what he ACTUALLY said.

Cameras and recording devices were strictly forbidden, and this was in the days before everyone had cellphones that could record anything.

meeps , January 12, 2016 at 6:44 pm

I don't know the date of this speech (the upload predates the 2010 debacle), but Obama stated, "I happen to be a proponent of single payer health care…"

That said, we got hosed. Each of us must now decide whether to roll over and take the corn, or, to demand single payer and the re-regulation of industry (the pharmaceutical industry and others that affect health tangentially).

meeps , January 12, 2016 at 7:38 pm

I've not been able to resolve the technical reason behind my missing links. You'll find the 53 second clip on youtube channel 6y2o12la titled: Obama on single payer health insurance.

sierra7 , January 12, 2016 at 1:57 pm

Oh, My! My!
Thank you Yves!!!!!!!!
You go to (as you are now) the head of the class!

nigelk , January 12, 2016 at 2:33 pm

One imagines Yves with a large staff and flowing robe…

"O-bots…YOU…SHALL…NOT…PASS!"

barutanseijin , January 12, 2016 at 5:28 am

You mean vested interests as represented by Obama and the Democrats.

Paul P , January 12, 2016 at 5:40 am

"the single payer solution that this Obama wanted"

Obama kept single payer off the table from the start. He would have had to decide to fight the industry and take the fight to the country. Medicare for All is a simple idea. He could have done a 50 state whistle stop tour. He could have saturated any Congressional district opposing Medicare for All with the same message. That wasn't his plan.

I attended one of his community meetings on health care, held around the country prior to him adopting Romney Care as his proposal. One of the organizers of the meeting starts off by complaining to the group about not just telling Obama we want single payer.

cwaltz , January 12, 2016 at 9:09 am

One of the first things Obama did was make the GOP party point men on health care(Olympia Snowe anyone?)

And it was Nancy Pelosi who called it impractical and took it off the table, heck she even went so far as to have some of the activists committed to being heard arrested for being disruptive. She then promptly gave a minority Blue Dog group the opportunity to co opt the debate to grandstand on abortion.

It's positively revisionism to blame the health care mess on GOP. It was Democrats who screwed it up from start to finish.

Paper Mac , January 12, 2016 at 6:11 am

The first step is admitting you have a problem, brian.

Myron Perlman , January 12, 2016 at 8:58 am

"Obama wanted'? Single payer was ruled out from the beginning. Advocates for that position were not permitted to be part of the discussion. Who knows what Obama wanted? Look at his actions on this and other issues to make a better judgment. My take is that it was a presidency of symbolism not substance when it came to policies.

Lambert Strether Post author , January 12, 2016 at 11:47 am

Not to pile on or anything, but I think a review of the bidding is in order:

I suggest the real constraints came from three sources, as indicated by their behavior from 2009, when battle for health reform was joined: (1) The Democratic nomenklatura , which censored single payer stories and banned single payer advocates from its sites , and refused even to cover single payer advances in Congress , while simultaneously running a "bait and switch" operation with the so-called "public option," thereby sucking all the oxygen away from single payer; 1 (2) Democratic office holders like Max Baucus, the putative author of ObamaCare - Liz Fowler, a Wellpoint VP, was the actual author - who refused to include single payer advocates in hearings and had protesters arrested and charged ; (3) and Obama himself , who set the tone for the entire Democratic food chain by openly mocking single payer advocates ( "got the little single payer advocates up here" ), and whose White House operation blocked email from single payer advocates , and went so far as to suppress a single payer advocate's question from the White House live blog of a "Forum on Health Care." (Granted, the forums were all kayfabe, but even so.) As Jane Hamsher wrote, summing of the debacle: "The problems in the current health care debate became apparent early on, when single payer advocates were excluded [note, again, lack of agency] from participation."

In short, if single payer was "politically infeasible" - the catchphrase of that time - that's because Democrats set out to make it so, and succeeded.

Brian, could you ask your boss to send us smarter trolls?

nigelk , January 12, 2016 at 2:52 pm

I appreciate that such takedowns are always link-filled and impeccably sourced, and though combativeness in the comments is not the prevailing tone of this website (happily), damn if I don't pump my fist when I read a troll getting cut down thusly.

Fake leftist trolls are the worst.

GlobalMisanthrope , January 12, 2016 at 12:48 pm

Maybe you're not an incredibly lame troll. Maybe you're just a poor beginner who unwittingly wandered onto the Varsity field. But if you "see little evidence of ideology in the result," you may want to look up the definitions of "evidence," "ideology" and "result."

James Levy , January 12, 2016 at 6:17 am

Educated elites with a modicum of leisure always love to play these games. It took them decades and the most draconian policies imaginable to break the habit of workers early in the industrial revolution of trading off pay for leisure time. The basic notion of every capitalist scold throughout the ages has been that this is irrational laziness, even if your job is a physically exhausting and soul-crushing exercise–you must work more, or you are a bad person who should be punished.

Now, it's the "let's turn everything into a market" game. Don't want to play? Screw you–we'll make it mandatory, and, of course, punitive. This goes way beyond Obamacare into every facet of our lives. Public utilities? Hell no–give them "choice"! Community schools? No way–can't have the races and the classes and the ability levels mixing in such a promiscuous manner–let's go charter "academies", or vouchers. It's a normative takeover under the guise of "rational" "scientific" "efficiency".

Jim , January 12, 2016 at 8:54 am

Wow, this is so right!

JustAnObserver , January 12, 2016 at 2:14 pm

Minor correction:

Public utilities? Hell no–give them Lead!

ilporcupine , January 12, 2016 at 6:06 pm

So true. Ask them about their golf game. It is only YOUR leisure time at issue, not theirs. Don't you wish you could count as "work" blathering your stream of conciousness on CNBC day after day?

ambrit , January 12, 2016 at 6:57 am

I remember that one of the 'talking points' in favour of Heritage Foundation Care (HFC) was that "pre-existing" conditions were not to be allowed to deny anyone coverage. Using that logic, it can be asserted that 'Poverty', absolute or relative, a pre-existing condition if there ever was one, denies 'patients' useful medical care.

The system as administered is internally contradictory. Taken one step farther, the HFC can be defined as a "Faith Based Service Provider." This would be an insult to actual traditional Faith based providers. Most "real" FBPs are governed, at least in theory, by ideologies that counsel 'compassion' when dealing with the less fortunate. As has been demonstrated, the HFC program counsels exploitation when dealing with the less fortunate. A case in point; this week a local religious charity opened a 'Free Clinic' in our town of 45,000 or so souls. The local paper put this on the front page. Buried in the body of the article was the mention that this clinic was fully booked up for the first, and probably second month. All this before public mention of it's existence. There's your 'Marketplace' in action. As I discovered when I looked into signing up for the Mississippi Medicaid program for myself, a family cannot have over 2,500 USD in 'assets.' There is an ongoing dispute as to whether or not an automobile classifies as an item counted toward this limit. Thus, those in our state who do qualify for Medicaid are poor indeed.

Carolinian , January 12, 2016 at 9:21 am

Using that logic, it can be asserted that 'Poverty', absolute or relative, a pre-existing condition if there ever was one

Great point. In the US we have a health care system that saves people's lives while–in many cases–taking away their means of living it. The Hippocratic Oath should be modified to read: first do no harm to Capitalism.

Ulysses , January 12, 2016 at 2:58 pm

Yes, it is an intriguing suggestion. Does commenter thatworddoesnotmeanthat care to elaborate? Were the architects of RomneyCare (and it's national extension Obamacare) attempting to recreate a golden age, of 11th century free peasants– happily enjoying the abundant commons of medical care, in the carefree forests and dales, before they slipped under the Norman Yoke of feudal exploitation?

Or, is the reference to some non-Western communist society that flourished in the mid-11th century? Perhaps thatworddoesnotmeanthat has studied early communist cultures in South Asia, America, or Africa that distributed healthcare in a way that eerily foreshadows what Romneycare did in Massachusetts?

James Levy , January 12, 2016 at 1:36 pm

The record is irrefutable–the ACA was written by the insurance companies with a wink and a nod to Big Pharma and the HMOs. Unless you are going to seriously entertain the notion that these are "communist" institutions, or give a rats ass about anything but making money, you can't really believe what you wrote. You are just angry about something and projecting your fears onto this travesty.

Disturbed Voter , January 12, 2016 at 7:37 am

The subsidies of Obamacare, if you qualify for them, requires the IRS to get intimately involved with your checkbook. Just like middle class folks want recipients of SNAP to be regulated with every food and drink purchase … matching what the bourgeoisie thinks matches their own moral rectitude.

I prefer not to make the IRS my intimate partner … helping me to define what is an asset and what is income to the last penny.

Wade Riddick , January 12, 2016 at 8:12 am

The idea behind high deductibles is that you'll force consumers to economize. It's kind of like telling science, "Hey. This patient needs ten pills to live? Let's give him eight and see what happens."

Medical treatment is a science issue. A treatment's either effective or it's not. You can negotiate the cost – *with the supplier* – but you can't bully a disease or injury into behaving the way you want. You certainly can't bully the sick person and they're in no position to negotiate with the supplier. They have none of the necessary experience or health. That's exactly the wrong time to try to educate someone about their "options."

But then that's the whole point. The medical market is intentionally littered with opacity. There is nothing transparent about insurance, much less drugs or surgeries. Medicine is increasingly dominated by complex bureaucratic cartels for exactly that reason – so you *won't* find out how things work. They don't want you comparison shopping for drugs, surgeries, therapists. Everything about the modern medical system is precisely about robbing "customers" of human agency.

The whole idea of shopping for health insurance itself is absurd. It requires you figuring out exactly how sick you'll be in the next year and then inventing a time machine to travel back so you can pick the Pareto optimal policy with exactly the best deductible – which really won't matter because then they'll find a way to make sure your E.R. wasn't in network nor your anesthesiologist and the only drug to keep you alive won't be "covered" and then you'll wish it was only an Arnold Schwarzenegger skin-wearing android sent to kill you 'cause that would be way easier.

They're removing choice left and right and destroying scientific information through lobbying. The people responsible for creating diseases aren't being held responsible for them but the victims suffering from them are.

When multiple sclerosis organizations are run by drug companies selling $50K+ a year drugs, do you think they want those customers finding out that deworming society is what created the risk for M.S. in the first place?

As Martin Shkreli put it, he has the perfect "price inelastic" product. Patients are a captive market that's easy to exploit. Either they get what they need or they die. You can charge what you want.

Do you think lazy executives looking to bump up next quarter's earnings are going to invest heavily over the long haul in scientific models of effective disease prevention and treatment or are they simply going to squeeze people a little more and a little more?

Let's not forget why politicians love the sickcare complex. The more an industry turns into a cartel, the easier it is to raise both economic and political rents from it. Let's be honest here and call a spade a spade. Politicians like this system because it easily feeds campaign dollars into the system. It may not be efficient for treating patients, but it's quite efficient for extracting political re

Crazy Horse , January 12, 2016 at 12:48 pm

Comparison shop for medical care in the USA? You've got to be kidding.

Case in point. My doctor recommended a cardiovascular "stress test" for diagnosis of heartburn symptoms to make sure that it wasn't cardiovascular in nature. I traveled to a regional heart specialist center for the test, but based upon previous experience refused to undergo the test until they put the bill for the procedure in writing including my deductible cost. The intake administrator acted shocked by such a request, and it took 30 minutes of increasingly strongly worded demands on my part before they finally produced a verbal quotation – which I recorded for future use if they decided to bill $12,000 for 10 minutes on a treadmill.

The world's most expensive health care extortion system at work.

Jim Haygood , January 12, 2016 at 1:49 pm

NBER: 'There is no evidence of learning.'

As Barry O. likes to joke, mimicking George W. Bush's drawl, "Is our consumers learning? Ha ha ha!"

Wade Riddick , January 12, 2016 at 8:15 am

political rents. (Got cut off for some reason. Arnold got me, I think.)

Winston , January 12, 2016 at 8:44 am

It's nearly impossible to "comparison shop" if you're part of an HMO these days. The only choice one really has is to select their PCP. After that the PCP pretty much forces you to see docs and get tests within the hospital system – presumably for "coordinated care". And this for nearly $1000/mo for a single person not receiving much in the way of "healthcare". That which can't continue, won't….

Jim in SC , January 12, 2016 at 8:49 am

One of the things that distinguishes the US from other countries is our high level of tax compliance. I'm concerned that these Obamacare penalties will lead to diminished compliance, both because people resent the penalties, and because it is such an intellectually frustrating exercise to try and estimate future income.

HotFlash , January 12, 2016 at 11:44 am

Perhaps not so ? Can you give me a link? TIA.

Jim in SC , January 12, 2016 at 10:08 pm

http://www.pappastax.com/american-tax-compliance-rates-highest-in-civilized-world/

allan , January 12, 2016 at 9:39 am

More like a flat screen TV, rented from Samsung, that functions like one of those old British hotel radiators that you have to feed with pence $60 copays every 10 minutes in order for Time Warner not to interrupt the streaming.
And then you get balance billing from Disney for the content.

Chromex , January 12, 2016 at 9:42 am

My experience is that there IS no "competition" in any product field that involves actuarial calculations. I get a subsidy and I am 63. There were about 50 plans offered in my area. A few were OVERpriced, yes, but the vast majority offered very similar premium prices, and identical elephantine deductibles, which means that except for aspects of the annual physical, it will "cover" ( assuming cover means pay for) jack. "Coverage" is not care, it is nothing to brag about. I am "covered" for expenses beyond my deductible as a form of catastrophic insurance but the plan will never pay for anything else and actuarially, it is easy to calculate a premium that guarantees that companies will make lotsa money while paying out less. Needless to say the "product" is outrageously overpriced for what it covers and puts people like me _- close to medicare but limited income and owns own house free and clear in a far far worse position than before the law. ( eg medicaid asset recovery if I dare to state a lower income etc etc). So I'm "covered" , so what. I have far less actual care. And that , it appears to me , is deliberate.
Even if it were "competitive" there is not much point in comparison shopping for flat screen tvs.. for a flat screen tv with X features made by brand "A" the price difference for a tv with the same features ( and longevitiy) of brand "B: will in the vast majority of online offerings, be so close as to not be worth the effort. This is even more true with insurance.

Like most politicians, Obama wanted to "do something" and a have a bill he could hold up in front of Everybody and say "see this is mine". My experience with such legislators/administrators is that they have a lot of hubris and grees for the bill to pass and do not subject potential downsides to any critical analysis so that advisers get the message "construct something that will pass" .The fact that he was dumb enough not to see this coming suggests that his "ideology" was driven by his advisers- who are definitely neocons IMO not neoliberals unless the term "liberal" is used in its classic economic sense.

And while we are on the subject, "Health care" is not really subject to "market" principles. Start with the fact that most people in this country have less than 1K savings, which means that they cannot cover the ginormous deductibles most "silver" plans offer or the premiums of better plans. Then add in the fact that these people cannot predict how much care will be needed in a given year or what the final cost of that care will be. What's the "market " for that? Under these two facts mandatory "insurance"with high deductibles and narrow networks simply functions as a wealth transfer from strapped lower-middle and middle class adults to Insurance company shareholders and CEOs.

Even assuming that Obama "wanted" single payer- an assumption that has been ably refuted in this string already, had he given "what can get passed" a moment's critical analysis, he might have realized that he- with his insistence on change for change's sake- was making it worse for so many Americans. I for one , could care less that pre-existing conditions are now "covered" if I can't actually use the coverage- pre existing survives, its now called high deducitlbes and narrow networks.

macman2 , January 12, 2016 at 9:59 am

Actually, as Winston Churchill famously noted, "Americans manage do the right thing after they have exhausted all of the wrong choices firs"t. So it is that had we gone right to single payer without this "market based" attempt, we would have heard howls of capitalistic remorse, etc.

So I am glad that Obamacare was attempted and that it is failing predictably. It is pretty clear to even the free marketers that high deductibles only impoverish Americans, that "skin in the game" does not make people better shoppers for the highly technical world of medicine, that price transparency is essentially worthless if nobody is comparison shopping while they are bleeding out from every orifice, etc.

Medicare for All is arguably catching on. Bernie Sanders poll numbers have not taken a dive with this promise and the sputtering Obamacare is only putting more fuel to this fire. Hillary's tax scare attempt will turn flat on its face. People know bad value when they see it, and the current market based health reform is failing into the predictable death spiral. View Bernie's ascendency as evidence that the American people think health care is a right and it is time to fund it that way.

marym , January 12, 2016 at 12:26 pm

Is the argument here that it was necessary for millions of people to suffer from lack of access to affordable healthcare, and tens of thousands to die, to teach us a lesson, because designing, advocating for, and rapidly deploying a simple, effective single payer system that would bring both immediate and long-term benefits that would silence even its would-be detractors is impossible even to imagine? This is why Democratic Party and Obama cheerleaders have no credibility anymore.

http://www.pnhp.org/news/2015/july/medicare-turns-50-and-we-have-much-to-celebrate

Also, while it's great that Sanders is bringing attention to this topic, it's not surprising that people are responding favorably People have been polling in favor of a Medicare-type single payer program for decades.

http://pnhp.org/blog/2009/12/09/two-thirds-support-3/

James Levy , January 12, 2016 at 1:44 pm

Americans have not and will not "do the right thing" on this issue because the entrenched interests that are making money off of the current atrocity that passes for a healthcare system are too strong to displace. Europe got single payer after WWII because the only institution in society left with access to money was the State, so doctors and hospitals after the war were going to sign on for socialized medicine because societies at large were destitute. Whatever the government will pay is better than grandpa's watch (if some conquering army hadn't stolen it) or a chicken (ditto). Until this situation comes into being here in the USA we're not going to see single payer tax-based healthcare.

Ulysses , January 12, 2016 at 3:13 pm

Your argument would make sense if Canada, which, like the U.S., never suffered the same WWII devastation as Europe, hadn't managed to build a national single-payer health system.

sleepy , January 12, 2016 at 10:16 am

And let's not forget the medicaid clawback provisions for those between 55-65. If you apply for Obamacare, and your income level is below a certain threshhold, you are not eligible for subsidies. You are placed into medicaid.

However, for those in that 55-65 age bracket, there is an estate clawback provision that effectively acts as a lien on your estate: once you die your assets will be seized by the state to satisfy all medicaid provided healthcare expenses.

Prior to Obamacare, in order to qualify for medicaid, not only was there an income requirement, but your assets also had to be below a certain, very low, amount. With Obamacare however, the asset requirement is waived for those in that age bracket.

What happens? Many who now are eligible for medicaid via Obamacare will now own a house as their primary asset of any significance. But once enrolled, that house will be sold on the insured's death to pay medicaid. I would assume that in states that have privatized medicaid, these sums will also include all premiums paid by medicaid on the insured's behalf-even if no claims are ever filed.

If that's not bad enough, under Obamacare to satisfy the law, the consumer is forced into this by the mandate. There is no choice. Beyond that, if the insured had an income level a few dollars higher, he/she would be eligible for subsidies which, of course, need not be paid back on the insured's death.

Clawback provisions, though with many exceptions particularly for those under age 55 have always been required under medicaid, but now medicaid enrollment will be required by law with actual assets available.

Medicaid is essentially a reverse mortgage.

sleepy , January 12, 2016 at 10:31 am

In terms of the assets issue, my comment is applicable to those states that have adopted the expanded medicaid features of Obamacare. As mentioned by a poster in Mississippi, states that have not, still have the old rules on having virtually no assets in order to qualify.

Spring Texan , January 12, 2016 at 11:56 am

Thanks, your comments are accurate; and this is something that is too little discussed.

ilporcupine , January 12, 2016 at 5:49 pm

I have seen this stated here on many occasions, over the course of the OCare debate. While the law seems to give authorization to clawback, in my state it only seems to have been used for nursing home and other long term care. I can state from my experience, I was never queried about assets, and was qualified only on income. I just lost the person with whom I have shared my life for 30 years, and her assets, went to her daughter without any claim from the state. Hers was an expensive battle with cancer, and did rack up a pile of charges. ( In my state, Medicaid is paying a private insurer to cover Medicaid patients). I have been reading here for a long time, rarely posting, I tend to agree mostly with the view here, but this seems to be widely different between states. I have no issue with Yves or Lambert on this, they have done yeoman work trying to get to the bottom of these issues. Just felt I needed to weigh in for the sake of completeness. Yves and Lambert you have my email if you want to discuss my experience, it is all to fresh a wound to discuss in this public forum.

Rob Lewis , January 12, 2016 at 10:39 am

No argument that Obamacare has some serious problems. But placing ALL the blame on the President seems excessive. Even if he had come out strongly for single payer, there are more than enough DINOs in Congress in thrall to Health Care, Inc. to have prevented its passage. And the Republicans would have dialed up their anti-reform propaganda to new levels of hysteria (Remember the anti-Hillarycare saturation media campaign? I'll bet Obama does.)

sleepy , January 12, 2016 at 10:55 am

When Obama was inaugurated he had more political capital in his pocket than any president in recent memory. The repubs were on the ropes.

Sure, the repubs could have gone all out in opposition, but as another poster mentioned Obama could have gone all out as well and blitzed the country. And in the first few months of his presidency, my bet would have been on him more than on the repubs.

Of course he did nothing. And to say he did nothing because of fear of the repubs at that point is silly. He empowered the repubs. He didn't even pretend.

HotFlash , January 12, 2016 at 11:33 am

Even if he had come out strongly for single payer…

Oh, but he didn't! If pigs had wings, perhaps they could fly? He could have, he didn't even pretend (like he did with closing Gitmo). Oh, concerned about his legacy? No problem, $peaking fees from insurance companies, pharmacos, $eat on bds of directors, his future will be golden!

Hello. "Leaders", elected or otherwise, sell out locals to corps = banana republic.

Have a banana.

Lambert Strether Post author , January 12, 2016 at 11:48 am

"placing ALL the blame on the President"

Match for that straw?

fb , January 12, 2016 at 4:43 pm

"All health insurance plans purchased through Covered California must cover certain services called essential health benefits. These include doctor visits, hospital stays, emergency care, maternity care, pediatric care, prescriptions, medical tests and mental health care. Health insurance plans also must cover preventative care services like mammograms and colonoscopies. Health insurance companies cannot charge copayments, coinsurance or deductibles for such services."

Yves Smith , January 12, 2016 at 7:05 pm

By taking that out of context, you've considerably overstated what Covered California covers.

Just as in the rest of the US, the "metal levels" have the same meaning. For instance:

Bronze: On average, your health plan pays 60 percent of your medical expenses, and you pay 40 percent.

This is the language from their "Essential Health Benefits" section:

Essential Health Benefits

All health insurance plans now share some common characteristics. The Affordable Care Act requires that all health insurance plans offered in the individual and small-group markets must provide a comprehensive package of items and services, known as essential health benefits.

These benefits fit into the following 10 categories:

Ambulatory patient services.
Emergency services.
Hospitalization.
Maternity and newborn care.
Mental health and substance use disorder services, including behavioral health treatment.
Prescription drugs. For more information about prescription drug benefits, visit the page Prescription Drugs.
Rehabilitative and habilitative services and devices.
Laboratory services.
Preventive and wellness services and chronic disease management. For more information about preventive services with no cost sharing, click here.
Pediatric services, including dental and vision care. Dental insurance for children will be included in the price of all health plans purchased in the exchange for 2015.
The requirement for insurance plans to offer essential health benefits is just one of many changes in health coverage that began in 2014.

So this is just ACA boilerplate. I do recall reading that Covered CA does require some services be provided irrespective of the deductibles (beyond the ACA-mandated preventive care items like mammograms, which separately are a bad test), but after 10 minutes of poking around the Covered CA site and other Googling, I can't find any evidence of what those other services might be. I thought it was at least a doctor visit or two, but I can't even find that.

And 75% of Covered CA plans have narrow networks, compared to 41% for the US as a whole, which among other things means you might not be able to get a specialist you need:

http://touch.latimes.com/#section/-1/article/p2p-84275268/

The site and web service are also terrible, see the long horror stories at Yelp:

http://www.yelp.com/biz/covered-california-sacramento

And see this from Kaiser News:

Most Insurance Exchanges Just Got Bigger. Covered California Is Getting Smaller.

http://khn.org/news/california-healthline-fewer-insurers-on-online-marketplace/

RUKidding , January 12, 2016 at 11:52 am

Obama NEVER tried one iota to go for Single Payer. Nada, Zip, Nothing.

Ergo, I place ALL the blame on Obama. IF he had tried even a teeny tiny bit, I could perhaps place some blame elsewhere. But factual reality refutes that.

I also do recall the POTUS taking Dennis Kucinich up in Air Force One, and when they landed, suddenly Kucinich had changed his mind and was (reluctantly in my viewpoint) giving an thumbs up on ObamaCare. Kucinich was the longest hold out advocating for Single Payer. Obama basically took him to school and forced him in some way to STFU and say Obamacare was the best.

Baloney. Obama sold us all to BigInsurance, BigPharma, BigHospital, BigMedDevice, and I'm sure he was handsomely rewarded.

This one, imo, is all on Obama. It was what he wanted, and it's what he now touts as being this very great thing, which it's not.

so , January 12, 2016 at 12:38 pm

No amount of dem. or repb. BS will ever persuade me to participate in national politics again.
obamas handling of the ongoing financial and health care crisis finished it for me.
It's so clear to me where were at. The corruption is sickining. EVERY DAY the stories. I keep thinking…."all the kings horses and all the kings men couldn't put Humpty back together again." Read The Archdruid Report for some insight. Everybody wakes up sooner or later.
In this life or the next

tegnost , January 12, 2016 at 11:30 am

Yes, definitely better to give up without a fight. Have you noticed that in spite of what is essentially a media blackout Bernie is likely leading in the polls? As to your opening statement "No argument that Obamacare has some serious problems" you admit to ACA shortcomings, maybe you would like to offer up some of what you see as good aspects of the ACA? Further, "there are more than enough DINOs in Congress in thrall to Health Care, Inc. to have prevented its passage. " there was and is a DINO in the oval office "in thrall to Health Care, Inc." who made no other option impossible. So much for the vaunted "free market" The ACA was designed and implemented as socialism for the 20% (h/t Lambert and others who have noted the upper class and their minions occupy the top quintile) whose medical care was getting too expensive, and whose medical (device, pharma patents, and insurance co.) investments were not being supported by demand, so the ACA created demand for them. Medicare for all, and get rid of the clawbacks, I personally would rather chromex's heirs get his assets rather than Blackstone, thank you.

Ulysses , January 12, 2016 at 3:25 pm

You jest, but in many late medieval and early modern Italian city-states there were ruthlessly enforced minimum consumption levels for salt. Prior to refrigeration salt was more of a food preservation necessity, but the huge consumption taxes placed on salt made them a fiscal necessity as well. Our word salary derives from the fact that so many government officials were paid from the revenues collected through salt taxes.

The much-hated gabelle in pre-Revolutionary France was a salt tax!

http://www.academia.edu/18012323/_Un_popolo_che_non_vorrebbe_sentire_nominare_dazi_esenzioni_privilegi_e_traffici_illeciti_tra_Brescia_Cremona_e_Mantova_nel_Settecento_versione_provvisoria_

Lord Koos , January 12, 2016 at 3:53 pm

No, a better solution would be forcing everyone to go in debt to own a large SUV… hybrids don't qualify.

tegnost , January 12, 2016 at 11:45 am

this was meant as a reply to rob lewis' post at 10:39

Rob Lewis , January 12, 2016 at 2:03 pm

I doubt you're really interested in a discussion, but here are a few very good things about Obamacare:
1. Elimination of pre-existing conditions as a reason for being refused coverage
2. Requirement that insurers spend at least 80% of their revenue actually paying benefits
3. Preventive care must be free
4. Expansion of Medicaid (where permitted by states) brings coverage to millions of previously uninsured
5. Standardization of plans makes is possible (if not easy) to compare them

And this is my opinion, but I don't think it would have been possible to get Medicare for All through Congress, even with Democrats nominally in control, for the reasons already stated.

Anyway, my whole point is that Obama doesn't deserve ALL the blame. Are you arguing that the public and Congress were ready and willing to enact single-payer, and Obama somehow prevented it?

Katiebird , January 12, 2016 at 3:44 pm

1. Pre-existing condition with the caveat that you must live in an area served by a medical establishment that specializes in your possibly rare illness.

2. 80% Yay! It's almost like Christmas! …. Cold comfort to those who must cough up $10,000 or more before getting any benefit from trom their policy at all.

3. Preventative care must be free. OK. So the $10,000 get's them a colonoscopy and a glucose meter.

4. Expanded Medicaid … In the states where it happened, anyone over 55 years old subject to an undisclosed clawback of benefits from estates. Wow.

5. I cannot imagine how you come up with the comparison justification. People have to sign up for plans without final commitments of which doctors or hospitals are included. And even then they are subject to change!

"Democrats nominally in control" … This is a pure deception. They had overwhelming majorities and wildly popular President. Do you seriously think that if faced with Obama's shaking finger and an enticing promise, that any Democrat would have defied him during those first 100 days. I laugh at the thought. He could ave gotten Expanded Medicare for All passed in those first 100 days with one hand tied behind his back.

bob , January 12, 2016 at 3:46 pm

Are you arguing that any single one of your bullet points is true?

For instance #1- covered? Covered by what? You can be covered and still not be able to afford the deductibles, or even the premiums.

The rest is talking point BS, tiny little grain of some sort of truth wrapped in ponies.

tegnost , January 12, 2016 at 9:55 pm

Thanks for responding. Yes it's good that pre-existing conditions no longer can be refused coverage,but one still needs to be able to afford coverage, so not being refused is not the same as receiving care, no? Your second point also has some merit as it appears intended to contain profiteering, but as one can see from martin shrkeli there's nothing stopping the greater healthcare marketplace from increasing costs, so the 80% becomes ambiguously beneficial. I did not know preventative care is free, but if that means as implied by another comment colonoscopies and other rather invasive procedures that might be seen as a cash cow with once again ambiguous benefits to consumers, really they are actually insureds, not consumers, as the prices are beyond peoples ability to pay, only insurers can ably do that, so the consumer is consuming insurance not care, I'm arguing for a gov't insurance and appreciate your opinion that it couldn't have been pulled off, as I think you are aware that my opinion is that they not only didn't try, indeed the executive branch stood between private sector healthcare industries and reform in the same way it stood between the banksters and those pitchfork wielding crazy people. Whatever your feelings about all that saving the economy stuff, it was largely and in many aspects a giveaway to people who were on the brink of disaster, a little more give and take would have been appropriate and the hope and change mandate provided the executive with considerable clout. Also, the medicaid expansion is a wolf in sheep's clothing as the clawback is regressive and punishes low income people as well as some probably good sized portion of people who will find themselves unceremoniously dumped into medicaid when their insurance and other medical bills drive them into financial distress. Lastly, the standardization of plans was in fact useful for me to figure out i couldn't afford it without taking to much time. I'll dilute my criticism of the president to be more inclusively the executive branch and their collective agenda, but basically the O man is the CEO so gets to be the hero, or the goat…

Adrienne Adams , January 12, 2016 at 11:35 am

As Chromex notes, Obamacare "coverage" is high-deductible catastrophic, so all day-to-day "care" is paid for out of pocket. But just try finding out how much a procedure costs… I needed an MRI on my knee, and it took three phone calls to find out how much I would be paying for the procedure. First you need to know the exact billing code for the procedure, which means you need to find the person in the doctor's office who is anointed in the mystical realm of billing codes; then you need to call the insurance company customer service rep, who is initially mystified that you are actually trying to find out how much something costs; then you (hopefully) transferred to someone in the billing department (who has never spoken to an actual patient before); and finally, if you are lucky, in two or three weeks you will revive a letter from another anointed person giving the actual out of pocket cost of the procedure-which will probably be different after the fact as "adjustments" are made between provider and insurer.

If we had to buy anything else in this fashion, we'd all be naked, starving, and out-of-doors.

craazyboy , January 12, 2016 at 11:50 am

It's a market.

nowhere , January 12, 2016 at 2:06 pm

Did you misspell racket?

ProNewerDeal , January 12, 2016 at 1:34 pm

I recall seeing a stat that the median adult net worth of USians was only US$37K, whereas in Canada it is US$80K. I wondered if the primary reason for the huge difference, is the presence of Canada-style MedicareForAll in Canada. It appears the US health system bankrupts you rapidly as in literal medical bankruptcy as per indivduals' examples in the "Sicko" documentary"' or bankrupts you slowly, as in these crapified ACA policies that charge ~$12K/yr before paying for anything besides the annual physical exam even within your "narrow network".

Yves, are you aware of any economist study which estimates the differential in financial net worth between barbaric USA & civilized Canada?

sleepy , January 12, 2016 at 3:16 pm

Apparently what the masters of Canada can't extract through healthcare debt, they do it through astronomically high real estate prices, exceeding our bubble high of 2007. Though there are signs of deflation, tiny 2 bedroom bungalows in Winnipeg–depressed Canadian flyover country–go for $300K. The same dump in Minneapolis is yours for $175K. And that's comparing economically challenged Winnipeg with relatively prosperous Minneapolis.

Yes, not paying $1200/month in health insurance premiums can go to that overpriced Canadian mortgage, but that's sort of my point.

And to ward off some comments–I am in no way stating that Canada's national health program causes high housing costs.

Crazy Horse , January 12, 2016 at 4:40 pm

And the median net worth in Australia and Italy, among other countries is well over 100k. Makes you wonder about American Exceptionalism.

ProNewerDeal , January 12, 2016 at 11:24 pm

America is exceptionally wack & Crapified (c) Yves, as far as life for the 99%ers probably in the lowest quintile within the OECD, even when including the don't-really-belong members like Mexico & Turkey. Meanwhile Murica, from everyday people to the elites, drink Murican Exceptionalist Kool-aid on how Murica is Always The Best, no need to ever learn from any other nations on anything.

ProNewerDeal , January 12, 2016 at 1:46 pm

I wonder if the "net present value" of money/time/stress cost of emigrating to a civilized nation like Canada for those USians fortunate enough to have a chance of doing so, is likely to be much less than the equivalent money/time/stress cost of living an entire life in the US & having to deal with the US Sickcare Mafia.

hemeantwell , January 12, 2016 at 3:03 pm

Lambert said:

I've found that when I talk to people about health care and health insurance; they're very defensive and proprietary about whatever random solution they've been able to cobble together

In my limited conversations I've noticed that, too. I've been left wondering if it is hard to for them to give a clear answer since they've had to engage in guessy speculation about what they, and their families, might come down with, and they end up having to imagine awful stuff and then discount the possibility of it occurring, so too bad for little Susie if awful occurs. Trudy Lieberman has given emphasis to the absurdity of asking people to bet on their health, and I'm guessing it's not just a matter of feeling embarrassed about weak actuarial skills.

Shilo , January 12, 2016 at 6:46 pm

Talking about how you coped with Obamacare gives a clear insight into your personal finances, something a lot of people are hesitant to discuss.

When I was young I was taught never to ask a rancher how many head of cattle he ran, because it's no different that saying, "Hey, How much money are you worth?"

jonf , January 12, 2016 at 4:21 pm

So where do we go from here? Help the republicans repeal it? Fix it? Frankly I don't know. We don't have a congress to fix or replace it -even if Sanders wins. I think it helps some people, mostly those on Medicaid. So repealing it doesn't make sense unless it can be replaced. Even saying this is a marketplace is an outright lie. These bastards are just stealing from us all. Rock and a hard place. Sanders is the only hope and that at times seems vanishingly small.

nihil obstet , January 12, 2016 at 5:16 pm

When Obama took office, The United States National Health Care Act, HR 676 , for a single-payer system of expanded Medicare for All, was in the House of Representatives. If I remember correctly, it had over 100 Democratic Congresspeople co-sponsoring it. Part of the Obama administration's efforts on its own health insurance bill were aimed at getting the bill withdrawn.

afreeman , January 12, 2016 at 8:31 pm

Thanks for that reminder. Reading the recent book, American President (from Teddy to Bill) helps one's recall considerably-telling contrasts between Presidents who knew how to pass legislation and the flukes (if assassination can be called a fluke, i.e. Devil's Chessboard) that brought them our way against those who didn't. For instance, LBJ compared with JFK, who had enough legislative service to learn a thing or two if he were interested, that is.

Too bad the book's so damn thick-well written and lively though it may be. Voters not likely to read it. Should though.

Malcolm MacLeod, MD , January 12, 2016 at 9:21 pm

Lots of arguing and different thoughts, but one primary fact remains. Obama was a bald-faced
lier from the get-go, and has remained true to that principle. He hasn't really tried hard to
question that. The amount of damage done to this nation during his tenure amounts to that
amount perpetrated by a traitor. Just being bad was "W"; this is actually far worse.

Malcolm MacLeod, MD , January 12, 2016 at 9:34 pm

Lots of arguing and different thoughts, but one primary fact persists. Obama has been a
bald-faced liar from the get-go, and has remained true to that principle. He really hasn't
tried hard to dispute that. The amount of damage done to this nation during his tenure
amounts to that amount perpetrated by a traitor. "W" was just bad; This is far worse.

ewmayer , January 12, 2016 at 9:41 pm

Related: Kentucky governor to dismantle state's health insurance exchange: newspaper | Reuters

Now, Kentucky being Kentucky, the motives here may be such that it is difficult for critics of the ACA to claim as any kind of 'win' – would any of our Kentuckian readers care to comment?

[Nov 05, 2015] Fake herbal supplements are more common then you think

observer.com

observer.com

Earlier this year, the New York AG investigated supplements at major retailers and found that four out of five didn't contain any of the labelled herbs. They contained "cheap fillers like powdered rice, asparagus and houseplants, and in some cases substances that could be dangerous to those with allergies." We're not talking fly-by-night Internet products; these are glossy bottles of so-called Gingko Biloba and Echinacea and Garlic, sold in stores like GNC and Target and Walgreens, with relaxing names like "Herbal Plus" and "Spring Valley":

1-rMEC1moEKkOBfuiGvH8Czg

When you buy a supplement, then, you're effectively on your own - not just in determining whether the supplement is safe and effective, but even in deciding whether you're eating what you think you're eating. Reload's packaging suggests it's an "herbal blend" full of plants like Gingko Biloba and Saw Palmetto, but tests show that it actually contains sildenafil, the strong prescription chemical found in Viagra itself.

This is a much freer market than people are accustomed to when they purchase anything from a reputable retailer, let alone something they plan to swallow. Absent stricter regulation, busy citizens count on the media to inform.

[Sep 06, 2015] ObamaCare to Crapify Health Insurance at 26% of Employers with Cadillac Tax

"...Btw a healthcare plan that impoverishes the middle class (who mostly do have employer provided insurance) to subsidize the poor (though Medicaid or lousy subsidized ACA plans) is a perfect way to divide and conquer most of the country, to set them against each other: "poor people and their ACA stole my health insurance!". While the hospitals and health insurers and PHARMA make off like bandits. Now you could have a health plan that is more likely to unite people than divide them but they didn't. Funny that."
.
"...The best plan is single payer. The big loser is insurance plans. Fairness doesn't result in insurance company skyscrapers and multimillion dollar salaries."
.
"...the HSA is its own kind of scam, with all sorts of mysterious fees and an inducement to put this money into suspiciously high-fee mutual funds… the privilege for which is yet another monthly fee."
.
"...Another thing about the job market is those full time jobs are becoming rarefied things, contract work is increasing. But even with one of those lucky full time jobs, the provisional with no benefits thing for 3 months is bound to cause problems."
.
"... Insurers are also tempted with the growth of the individual market instead of employer or government based Healthcare because an individual has no power."
Sep 05, 2015 | Economist's View
Sep 04, 2015 | naked capitalism
Praedor September 4, 2015 at 12:50 pm

Hell, even without the "cadillac tax" in effect, just plain old ACA, my healthcare has already been crapified. Before Obamacare, the wife and I had health insurance from our university that we both liked. It worked. It was based on the co-pay system and the co-pay was never onerous. Since ACA, however, the healthcare plans at the university have gone to shit. To keep health insurance that was at all similar to what it was pre-ACA would cost us an arm and a leg, and no, our wages are not high (by a LONG shot). Instead, we've been stuck with a deductible shitpile with a deductible high enough to really hurt ($3000) PLUS shitty coverage on top of that. Last year I thought that since I'd gone through my deductible for some back injury treatments, that a subsequent procedure would be rather cheap (to me). HAH! Got hit with THOUSANDS of dollars in bills leaving me to wonder just what the FUCK is the deductible for! Can't WAIT to see what happens after the cadillac tax goes into effect. Will the shit I've got now hit that threshold? What knock-on effects will there be? What will be the neoliberal trickle down?

Our pay will NOT be going up in any case. It has been YEARS since anyone but some useless administrators got any kind of pay increase. Pay increases, such as they are, for the real staff have been in line with the interest you can make on a savings account at a bank. Whooopie!

reslez September 4, 2015 at 5:15 pm

My employer offered a co-pay style plan until 2 years ago (ACA hello!) and now exclusively offers a high-deductible plan with a Health Savings Account. And yes, the deductible only applies to some charges, there are actually multiple deductibles, so you end up forking over a slice of your paycheck for potential access to care, but the insurer never pays a single thing, they only negotiate what you pay. And yet the threat of medical catastrophe and being driven into bankruptcy for a single incident (a vehicle accident, for example) looms over all of us. The neo-liberal world sheds no tears, it only counts money.

And the HSA is its own kind of scam, with all sorts of mysterious fees and an inducement to put this money into suspiciously high-fee mutual funds… the privilege for which is yet another monthly fee.

NotTimothyGeithner September 4, 2015 at 6:39 pm

The Obots will blame you for not clapping, not Obama or anyone who conned them. The one thing people hate more than con men is being conned themselves. The bright, wonderful people who snicker at Palin can't be had. They are just sports fans for the most part except for a sport even more harmful than the NFL.

If they hit rock bottom, they might recognize the connection.

Sean September 4, 2015 at 1:03 pm

I love the fact when I don't have a job (like now), I get penalized for not buying a product I actually can't buy because the "marketplace" closes in March.

Also, how am I going to pay these premiums without income? How do I pay my taxes without a job?

Neoliberalism has to die. Somehow. Or else it will kill us all.

jrs, September 5, 2015 at 9:13 pm

Something I have noticed about the job market, more and more employers for full time jobs won't pay for health insurance until your about 3 months into the job. So what are people supposed to do for those 3 months? Live without health insurance? Risky, but more importantly what about the penalties? Could those kick in if you don't have healthcare for 3 months? Does the ACA require continuous coverage to avoid penalty? Use Cobra from a prior job? It's insanely expensive. Private marketplace outside the exchanges? Might work depending.

Another thing about the job market is those full time jobs are becoming rarefied things, contract work is increasing. But even with one of those lucky full time jobs, the provisional with no benefits thing for 3 months is bound to cause problems.

oho , September 4, 2015 at 1:23 pm

perhaps in 2016 the nearly-always-thrown-under-the-bus Democratic foot soldiers finally wake up to the mistreatment that they've suffered at the hands of the Progressive Policy Institute/DLC/corporatist crowd .

OIFVet, September 5, 2015 at 5:34 pm

now they're holding up the bad parts they insisted on, ignoring the good ones, like access to health care for chronic conditions and previous flaws in health

What "access"? Take the narrow networks and the very high deductibles that are the mainstay of the "exchange", and what you call "access" is no better than what came before Obamacare. Many people still can't afford to go see a doctor because of that $6k annual deductible plan, the only one they could afford, and if they do have a serious health event they can't even know ahead of time if all of their medical team is in their plan, or will they end up paying for out-of-network providers. So you can easily throw another thing Obamacare failed to fix: bankruptsies due to medical costs.

Confirmation bias my a$$, I spent literally days of my life (the "time tax" Lambert talks about) trying to find the least awful plan my mother could actually afford, on a malfunctioning "exchange" offering very little useful info on the various plans' provider networks.

It's an overpriced PPO plan that I found. It has a 6,500 deductible, but it has one semi-decent feature: large provider network. Everything else about it is awful, so it is simply a catastrophic plan, at best. For some chronic conditions my mother does have it is useless, she refuses to go see a doctor because she can't afford the out-of-pocket costs and refuses to allow me to pick up any of her costs. You call that access? You are a bloody Obot apologist, and that makes you an awful person. Yet here you are blaming me and others here for having the gall to point out the load of crapiness that is Obamacare. Go eff your righteous self.

jrs, September 5, 2015 at 9:06 pm

FWIW those who have talked about personally experiencing increased access in my experience have mostly been those with expanded Medicaid who are not actually dealing with the exchanges. Medicaid is a mixed bag and often partly privatized as well, but I don't think it has the huge deductibles (there are clawbacks but not everyone cares). Of course they could have just expanded Medicaid without even bothering with the entire rest of the ACA and it would just be straight expansion of an existing government program.

OIFVet, September 5, 2015 at 9:46 pm

Right, Medicaid. For those who actually work there is no Medicaid, just some subsidies for lower middle incomes and no subsidies at all for some with higher income (in Chicagoland, the cutoff for subsidies based on the second lowest Silver plan premium is just under $40k, which is hardly "high income".

For them, crappy plans are the norm. Then there is the shrinking pool of providers who will accept Medicaid patients, and the clawbacks that can become an issue for some later on. Some may benefit, but those are mostly the ones with comfortable incomes and preexisting conditions. For the rest, "access" is a theoretical concept at best.

I take this very personally because of my prior family history. My father died at the ripe old age of 62 for lack of access. For him it was a choice between paying the mortgage or paying a high medical bill (preexisting condition). He could have never have afforded to pay the Obamacare premiums and their high deductibles, and he wouldn't have qualified for the expanded Medicaid. What would one do, give up his income to qualify for Medicaid and lose his home in the process?

Obamacare does absolutely nothing for those hard working lower middle class incomes, but here is this bloody Obot talking out of his a$$ about stuff he has no experience dealing with. So eff him and his effing hobby horse he rode in on. People like that are part of the effing problem, but he has the gall to lecture us about this travesty. Eff him, it's been years since my dad passed but it still hurts given the circumstances and what they reveal about the priorities of our elites. I simply couldn't let this douchebag spout his damned nonsense about the great "access" our oh-so-benevolent Barry has so graciously provided for a few people.

Praedor, September 4, 2015 at 4:14 pm

The biggest flaw with ACA or any other scheme ALLOWED to be considered by the Dems or GOP is that they always start with the question, "What's good for business?" instead of, "What's good for patients?" Starting off with the conceit that any healthcare setup MUST be good for business, first and foremost, automatically creates crap. The ONLY question that should be considered with designing or changing the healthcare system is, "What's good for patients?"

What will see people, regardless of economic class, receiving the healthcare they need to lead happy and healthy lives? It is totally irrelevant if a healthcare system design hurts insurance companies, private hospitals, etc. Healthcare isn't there to provide profits for CEOs and shareholders, it is there to provide HEALTHCARE. The poorest poor should receive the exact same level of care as the richest crook. The poorest poor should receive equal cancer treatments to the richest hedge fund looter, should receive knee replacement surgery equal to that of George Soros. Period. Any doctor that wants to be a doctor to get rich should lose his/her license to practice medicine. The Hippocratic Oath says nothing about getting rich, driving the finist Mercedes, or living in the Hamptons.

Oregoncharles, September 4, 2015 at 5:11 pm

Since you didn't get to the politics, a quick review:

The ACA passed WITHOUT ONE SINGLE REPUBLICAN VOTE. The big, bad Rethugs were irrelevant, and had been all along. This is absolutely something the Democrats did, all by themselves, complete with botches and knives in the back for their supporters – who in some cases still support them.

greensachs, September 4, 2015 at 6:19 pm

—the barriers to care will rise for an increasing number of Americans who won't be able to pay the high out-of-pocket expenses required.——- And when they develop major medical problems for which care is essential, they will face the difficult choice of paying for the needed care and having to default on their mortgages and other financial obligations, or not obtaining the medical treatments required.—

There is a reality that is altogether being omitted from the above truthful, yet pathetic narrative.

Many, are altogether avoiding treatment or trying DIY remedies. Even if there's an effort for partial diagnosis and/or treatment, again, many cancel or no-show the follow ups. Together, all of these, make U.S. "healthcare" a word with very little meaning. Hope, becomes your default coverage.

Welcome to the Neo (new) liberalism…the "free" (manipulated, fixed & phony) markets.

…the market based Hopium, which the last two administration have prescribed so unconditionally, is stamping out and forcing downward our humanity.

LAS, September 5, 2015 at 10:59 am

Economically, this kind of insurance transitioning was happening well BEFORE ACA (Obamacare). Expensive health insurance plans were going out of existence due to adverse selection anyway. Adverse selection was driving them out of existence before ACA (Obamacare). Read "Paying for Health Insurance: The Trade-Off Between Competition and Adverse Selection" by Cutler and Reber.

I think you attribute to ACA changes that are really due to healthcare economics. The ACA makes a nice target but it is not the root of what's happening.

tegnost, September 5, 2015 at 11:10 am

Au contraire! The ACA was designed to save those insurance companies whose business model was failing.

jrs, September 5, 2015 at 4:51 pm

If it's happening anyway why literally penalize employers that offer good insurance? No, I'm not buying it. While I agree it may have already been a trend to some extent this simply has to have an effect and magnify it, 40% tax hits do change employer behavior.

Ormond Otvos, September 5, 2015 at 4:55 pm

The best plan is single payer. The big loser is insurance plans. Fairness doesn't result in insurance company skyscrapers and multimillion dollar salaries.

Ormond Otvos, September 5, 2015 at 4:58 pm

In the absence of such studies of medical bankruptcies, one would be advised to have a tentative opinion, labeled as a guess.

And the confounding factor, thank you Mr Biden, is the rewritten bankruptcy laws immediately preceding the ACA.


jrs, September 5, 2015 at 2:22 pm

Btw a healthcare plan that impoverishes the middle class (who mostly do have employer provided insurance) to subsidize the poor (though Medicaid or lousy subsidized ACA plans) is a perfect way to divide and conquer most of the country, to set them against each other: "poor people and their ACA stole my health insurance!". While the hospitals and health insurers and PHARMA make off like bandits. Now you could have a health plan that is more likely to unite people than divide them but they didn't. Funny that.

Ormond Otvos, September 5, 2015 at 5:00 pm

A very insightful comment. Politics is run by lobbies who are paid by corporations. No one likes to admit that we, the voters, enable all this crapification by having little knowledge or interest until the financial pain finally hits.

Too late, then. Vote for Bernie.

Davidt, September 5, 2015 at 8:00 pm

There is and has been a trend to shift more of health care costs away from "insurance" or "government" (Social Security) onto having the individual pay more out of pocket.

Insurance companies have reduced payments to doctors, hospitals and we can be sure the drug companies. The drug companies have responded by raising the "list" price of drugs. This may be one of the reasons for the rapid rise of drug prices. Cost shifting from insurance companies to individuals. The question is where is that reflected in the price of insurance. Are the books of the insurance companies audited? Why the shift to individuals for increased medical costs. Most medical costs are not optional, they are controlled by the ordering physician. Hospital costs are worse. There is no way for an individual to control or influence most hospital costs.

Why not only measure outcomes for doctors but also costs of medicines?
My doctor claims he does not know the prices. This is a big problem.

Who benefits, what started this, and why is this taking place?

NotTimothyGeithner, September 5, 2015 at 8:46 pm

Ted Kennedy was the primary sponsor of the HMO Act of 1973 which ended the ban on for profit medicine. Even Dick Nixon thought the legislation sounded fishy. The health care system in this country was largely built by non-profit operators and small time independent agents (doctors). They would have been the primary distributor of pharmaceuticals and wouldn't have had incentive to collude for fear of prison.

Even now, I would contend insurers are a bit of a red herring compared to Big Pharma and the HMOs. They aren't seeing honest bills either. Insurers are also tempted with the growth of the individual market instead of employer or government based Healthcare because an individual has no power. If an employee where my father was an attorney had a health insurance issue, he would call the relevant regulators who would take his call because there was a working relationship. If there was guff, they would sue anyone and everyone. They would act, but the woman who sells tea cozies at the community market doesn't have a team of lawyers on hand in a private market place. Small companies had problems with insurance for similar reasons. If I recall, 93 Hillary care was very concerned with creating pools for the small operators.

The doctors and nurses ideally learned about medicine. Accountants and actuaries handled the other side and still do, but now everyone works for share holders not non-profit boards. The guy with his name on the building will be well cared for, but the hospital didn't exist to enrich him beyond advertising.

[Oct 28, 2013] OBoZoCaRe BoNaNZa!

Zero Hedge

Below is Kunstler's description of our medical situation. All that needs to be pointed out is that the republicans are primarily the ones responsible for opposing the kinds of fixes that would have gone a long ways to remedy the situation. A single care provider approach means cutting out the sleazy tribe of middle-men who make our way of fleecing the ailing public so profitable. The prime directive of the republican party is at all costs protect the unholy wealth of those who already have most of it...

The ObamaCare piece of the picture is a mere pathetic soap opera compared to the first two quandaries. The 2000-page law did nothing to address the core tragedy of medicine in America — namely, that it has evolved into a hideous hostage racket. You go to a hospital with a terrifying illness and you are susceptible to fleecing by the so-called “care-givers” for the promise that you may get to live. No prices for treatment are never discussed. They are presumed to be astronomical — but who cares if you end up dead, and if you do get to live, you’ll figure that out later. If you hold an insurance policy, these charges will be subject to a fake negotiation between grifting insurance companies and grifting hospitals, physicians, and drug companies. The price “settlements” are only slightly less a joke than the actual charges, and are obfuscated in documents designed to bewilder even well-educated policy-holders.

Even if you are insured, the charges may bankrupt you. A typical one-day charge for “room and board” in a non-specialized hospital in-patient bed runs $23,000 at my local hospital. For what?

Half a dozen blood-pressure checks and three bad meals? You can be sure that ever-fewer families will be able to fork over $12,000-a-year for basic coverage.

The ObamaCare legislation and its laughable rollout of a useless website is just a punctuation mark at the end of the soap opera script.

The result eventually will be the complete implosion of the medical racket and a return to a very primitive clinic system, with payment in chickens or cords of stove-wood. The smaller number of surviving humans will surely enjoy better health, and greater piece of mind, when this monster racket expires of inertia, bad faith, and deceit.

[Nov 03, 2011] The profit in keeping you ignorant by Wendell Potter

iWatch News

Health insurance industry and its corporate allies are fighting requirement that policies be understandable By Wendell Potter6:00 am, October 31, 2011 Updated: 1:21 pm, October 31, 2011 PrintE-mail6 inShare. Columnist Wendell Potter Robin Holland If you have no idea what you’re paying good money for when you enroll in a health insurance plan, there’s a good reason for that: insurers profit from your ignorance. And they’re waging an intense behind-the-scenes campaign to keep you in the dark.

In my first appearance before Congress after leaving the insurance industry, I told members of the Senate Commerce Committee that insurers intentionally make it all but impossible for consumers to find out in advance of buying a policy exactly what is covered and what isn’t and how much they’ll be on the hook for if they get sick or injured. Insurers are quite willing to provide you with slick marketing materials about their policies, but those materials are notoriously skimpy when it comes to useful information. And the documents they provide after you enroll are so dense few of us can understand them.

In the months following my Senate testimony, lawmakers drafting health reform legislation included a provision requiring insurers to both provide comprehensible disclosures of health plan benefits and make that information available to anyone shopping for coverage. Despite repeated attempts by industry lobbyists to get that provision stripped out of the final bill, the Affordable Care Act as signed by President Obama last year requires that all private health plans provide consumers with a concise and understandable Summary of Benefits and Coverage (SBC) form. In addition, they must provide a uniform glossary of medical and insurance terms.

If you think that sounds like a reasonable request, you’re not an insurance company executive who is rewarded more for meeting Wall Street’s profit expectations than assuring that consumers know what they’re buying.

Now the Obama administration is trying to figure out how to enforce this new requirement, and so health insurers and their allies have launched a full-court press to persuade government officials to gut it by exempting policies sold where people work. Because the vast majority of Americans who have coverage get it through their employers, this would mean that most of us would, for all practical purposes, continue to have to buy a pig in a poke.

Fortunately there are several organizations, including Consumers Union, publisher of Consumer Reports , that are fighting the good fight. They’re demanding that Obama officials write the regulations to apply to all health plans, regardless of whether they are sold on the individual market or through employers, unions or other groups. They insist that Congress intended for the standard form, which would allow “apples-to-apples” comparisons of health plans, to apply across the board.

As Consumers Union noted in comments sent to the administration, the booklet describing benefits that most employers currently provide their workers “is a bulky, legalistic document that few consumers can understand.” It cited one study which concluded that the typical benefit description document provided by employers is written at a college reading level. Most Americans have trouble understanding information written above the 6 th to 8 th grade level.

Insurers and their corporate allies, including the U.S. Chamber of Commerce and the National Association of Health Underwriters, are claiming in comment letters to the administration that providing a uniform, simplified and understandable version of those documents would cost so much money they would have to increase premiums.

America’s Health Insurance Plans (AHIP), the lobbying and PR group for insurers that says it represents more than 1,300 health plans covering 200 million people, contends that the cost of implementing the proposal would be $188 million. In addition, AHIP says, the annual cost of providing the information would be $194 million. Would insurers consider absorbing those costs? Of course not.

“The benefits of providing a new summary of coverage document, in addition to what is already provided to consumers, must be balanced against the increased administrative burden that drives up costs to consumers and employers,” AHIP said in its letter.

Nonsense. Consider this: the five largest insurers (UnitedHealth, WellPoint, Aetna, CIGNA and Humana) over the past week have reported profits exceeding $2.6 billion for just the three months that ended September 30, 2011. Over the past 10 years, those five companies have recorded profits of more than $50 billion. Imagine what the total would be if you added in the profits of the other 1,295 health plans AHIP says it represents.

The industry could even pass a hat among the CEOs of those big insurers and come up with the additional money without any one of them giving until it really hurt. UnitedHealth’s Stephen J. Hemsley is the highest paid CEO in America, according to Forbes magazine. He hauled in more than $100 million last year alone. When H. Edward Hanway, my former CEO at CIGNA, retired at the end of 2009, he walked out the door with $111 million. When you consider the money those two guys have made over the years, they alone could cover the cost of providing consumers with information they can understand.

I’d advise everyone to keep their eyes on this skirmish. If the administration caves to the insurers’ demands on this, we’ll know who really is calling the shots when it comes to implementing health care reform.

[Feb 08, 2011] guest-post-why-small-business-isnt-hiring-and-wont-be-hiring

by cxl9
on Tue, 02/08/2011 - 12:49
#943358

$1000/month for health coverage? Really? I am a 43-year old man who pays $369/mo. for a Kaiser gold policy + prescription. A young person could expect to pay half that. Anyone who believes health care is overpriced or unaffordable is simply hoping the government will force someone else will pay his medical bills.

by docj
on Tue, 02/08/2011 - 13:01
#943378

Good luck finding a "state approved" health insurance policy in the People's Republic of MA for under $1K/mo. (Thanks for that, Mitt Romney.)

by ThirdCoastSurfer
on Tue, 02/08/2011 - 14:31
#943751

Thanks to QE2 I have High Blood Pressure and "suddenly" don't qualify for traditional insurance. I applied for and qualified for "Obama Care" through www.pciplan.gov.

For $400 a month it carries a $2,000 deductible and a $5950 Out of Pocket max (OOP). http://www.pciplan.com/forms/pdfs/2011BenefitsSummary.pdf

So, from Year to Year, I can expect to pay $4800 in premium and $2,000 deductible equaling $6,800 before coverage begins and then I'll pay 20% of the next $19,750 before the OOP max is reached.

It was hard for me to fathom why I would chose (or in 2014 be forced) to accept such terms rather than just pay cash in the hopes that no one annual bill would amount to more than $10,750 (Premium + OOP) until I looked at the cost of random things like an appendectomy or a ER visit for a broken bone, each of which can easily cross $20,000 in expense because of the way hospitals, and health care in general, "upcharge" and "unbundle" their charges. Apparently, no one pays the listed price, so why all the confusion? I have no idea but is it possible that for tax purposes the difference can somehow be applied as a taxable loss as a business expense?

"Talk about what a tangled web we weave"

by blunderdog
on Tue, 02/08/2011 - 15:54
#944043

If all this info is accurate, and you're not happy with the "Obamacare" option, why not just skip the health-insurance and pay the fuckin' tax penalty?

Who in the world even wants health-insurance?

It's the ultimate definition of a sucker bet: insurance against shit you could *never* want to happen in the first place. If it pays off, you lose. If it doesn't, you lose.

I *know* some of these folks, and I'd predict: if something horrible happens to you and fucks your world, you're really not going to give a shit whether you can pay your bills for the emergency surgery.

by Dr. Sandi
on Tue, 02/08/2011 - 17:56
#944520

Once you get on the actuarial bad side of 55, the odds look a lot different.

You can stiff the hospital and all the various hangers-on for the first visit. But you're screwed if you ever have to go back there and don't have cash or credit card in your drooping paw.

by blunderdog
on Tue, 02/08/2011 - 18:09
#944556

Yes, I do actually appreciate that, which is why I say "IF" it looks like a bad deal, fuck it.

What I can't get over is listening to folks bitching about health-insurance costs on the one hand, taxes on the other hand, and outrageous health care expenses on the third hand. No one HAS TO take BP medicine. No one HAS TO have dialysis (or their kidneys replaced) after a decade of *not* taking BP medicine.

The money either has to come from somewhere or it doesn't--if it doesn't, just stop paying and die already. It's no one's fault that people get old and die, right? Your health is going to fail you no matter who you are or what you've done. If you don't want to pay for health-care, DON'T.

Just don't whine about it if you choose to pay. And don't blame government for the fact that you want the best possible care available and "money is no object" as soon as you reach that point, but it's a waste of your tax dollars as long as you feel ok.

Most people I know are completely infantile on this subject. It's no wonder no one's happy with our "policies."

by braveneweconomy
on Tue, 02/08/2011 - 12:55
#943379

Same here. I'm an independent contractor mid-40's and pay about $400/mo. for great coverage. I'm always perplexed by the people who scream about health care being too expensive.

by minus dog
on Tue, 02/08/2011 - 13:26
#943496

Sure, you can get insurance for $250/mo (assuming you can afford that - many cannot) but it doesn't do you any damn good for the sort of routine medical care someone my age actually uses. I typically get a huge cash discount, so my bill is essentially the same as if I were paying for the services with insurance... and without the monthly overhead.

Even at 250 a month, I'd be paying about 10x as much per year for medical and dental expenses. Even with the occasional serious injury every 3-4 years (about $3k a pop) I'm still coming out ahead.

Complaints about "freeloading" are going to fall on deaf ears - two words: Social Security.

This article is spot on; the system exists to fuck us and empty our pockets, why the hell would be participate in it?

by RKDS
on Tue, 02/08/2011 - 13:37
#943517

It would've been interesting for you to provide a salary for comparison, because to someone making $30K and taking home less than $2K per month, $400 right off the top actually _is_ expensive. And it's even worse if your employer doesn't offer coverage and you have to pay even more on the individual market.

by minus dog
on Tue, 02/08/2011 - 18:24
#944590

And, as people seem to keep forgetting, median individual income is somewhere around $26K

by HungrySeagull
on Tue, 02/08/2011 - 14:00
#943602

I know one retired dentist who endured 1200 dollars coverage per month for the wife. The moment the wife hit 65, medicare kicked in and he pockets the 1200 dollars per month.

HOORAY!

And if anything happens beyond what medicare pays, cash paid to billing all done.

by Mercury
on Tue, 02/08/2011 - 12:57
#943391

The acid test isn't whether or not your premium checks get cashed but whether or not you get what you need when you blow a gasket.

by tmosley
on Tue, 02/08/2011 - 13:15
#943456

Exactly. My company changed insurance this year and I went to the dentist for a regular checkup+x-rays. The insurance only covered half of the cost! This policy was the same price (to me) as the older one.

I would hate to see what happens if I were to actually have to go to the doctor or have some surgery.

by TheDriver
on Tue, 02/08/2011 - 13:40
#943556

I'm happy to fill you in on those details. As a 40 yo with reasonably priced coverage who had to face 2 unexpected, unrelated surgeries in as many years, I can tell you how bad things really are. I'll leave the country for future surgeries and pay cash. Even with airfare and lodging costs, it would be cheaper than having the work done in the US.

by HungrySeagull
on Tue, 02/08/2011 - 14:04
#943615

I had two insurance policies.

Both of them fought over a 16,000 dollar Ride in a MRI machine some time ago. They paid it. Then they fight over several surgeries I have had. They paid that too.

The moment Obamacare became law, I canceled both insurance companies and go to cash. If my doctor can fix a boo boo, great! Otherwise I make do.

I learned a month after cancelling for myself and spouse, our premiums would have gone up from about 870 a month to 1450 a month and some services cut back or disallowed.

Sorry. I am not putting money after a company that is cutting back.

Oh the small details about hospice, burial, cremations and all of that is already prepaid and arranged. One phone call does it all.

by baserunr
on Tue, 02/08/2011 - 14:07
#943631

See, here's a disconnect. Insurance is to cover the cost of expensive, unexpected-type events that have a small chance of occuring. If you are going to the Dentist for a "regular" check-up, that doesn't meet the criteria of what "insurance" is designed to cover. Many insurers have found a way to earn additional premium by expanding the boundaries of what they will "insure". That doesn't mean it is such a great deal for the insured; it just means the company can earn additional premium. If you work to keep the insurance for large, unlikley, and calamitious expenses, you'll probably find it very affordable. Pay cash for the rest.

by cxl9
on Tue, 02/08/2011 - 13:44
#943565

Agreed. I have been with Kaiser for years, and I can say that the service has been great. I have no complaints whatsoever with the medical treatment. I plan to stay with them for as long as I possibly can, at least until private health providers are eliminated in the United States and all of us are waiting in line down at the Post Office to get our health care.

by Thunder Dome
on Tue, 02/08/2011 - 12:58
#943394

I'm covering a family of four in the great state of Illinois--$20,000/yr not including dental.

by Threeggg
on Tue, 02/08/2011 - 15:32
#943955

Thunder you are doing better than me. (by $18 dollars) I pay $1718.00 for a Blue Cross Blue Shield Policy in Illinois. (it includes dental) That is for 3 people that are healthy.

I am looking into a major medical policy with a large deductable as I will pay for the regular medical expenses out of my pocket.

The medical sham put forth by Bamy raised all the prices. Now that they have the prices up over the rainbow they now want to repeal it. !

Prepare yourselves peeps as this running financial shit-train is pulling into the station.

[Mar 29, 2010] Will the GOP Remain the Party of No?

This is from The Myrtle Beach Sun:
DeMint, Graham let S.C. down on health care overhaul, by Isaac Bailey, The Myrtle Beach Sun: Two South Carolina legislators had the opportunity to shape the historic health care bill President Obama signed into law on Tuesday... Because the Senate version of the bill was going to be the foundation of the law, Sens. Lindsey Graham and Jim DeMint were our only two politicians who could have forced even more conservative ideas into the legislation. ... Neither did. Both shirked their responsibility to the state to walk lockstep with the GOP.
There was little reason to expect anything different from DeMint, who represents the party's Rush Limbaugh-wing. He didn't begin the debate saying we must find a way to bring down S.C.'s high percentage of the un- and underinsured. He didn't say we must find a way to stem costs that are spiraling out of control, bankrupting hard-working people for the sin of getting too sick. He didn't say the days of uninsured families having to leave coffee cans decorated with a sick loved one's photo on convenience store counters must end. He didn't say that if reform included strong tort reform so doctors would no longer feel the need to perform unnecessary tests that he would vote for it.
Instead, he said reform's defeat would be Obama's "Waterloo", that it would break the president. Only after his comments ignited a firestorm did DeMint propose a policy that most experts considered laughable. He was focused on politics, not people.
Sen. Graham began the debate differently. He knew if nothing changed, our health care system would eventually bankrupt us, which is why he initially supported the bipartisan Bennett-Wyden bill. ... But the proposal went nowhere fast. Instead of Graham engaging in the fight to incorporate the best parts of Wyden-Bennett - or any other effective plan - he fell in line with the rest of the GOP caucus.
He, too, became more concerned about his party's positioning for November than the people he was sent to Washington to represent...
The most vulnerable South Carolinians ... needed Graham and DeMint to lead. ... They didn't. Instead, they stood for the petty and ignored the real needs of the people. History won't forget. And neither should we.

And, from the local paper this morning:

Move past ‘repeal, replace’, Editorial, Register Guard: Republicans are preparing to march into the 2010 election under the dubious banner of “Repeal and replace!”
It’s a losing strategy, one that GOP lawmakers should rethink before venturing too far down that road. The health care reform bill has been signed into law. ... The Republicans should turn the page on health care if they want to shed the “party of no” label that served both the GOP and nation poorly in the debate over health reform.
That doesn’t mean that House Minority Leader John Boehner and other Republican leaders should publicly embrace Obamacare. That’s unrealistic; their philosophical differences with Democrats on reform are too deep and broad, and Republicans resentment over President Obama’s historic achievement precludes even the pretense of a political truce.
But Republicans face long odds in any attempt to repeal and replace health care reform, and they know it. ... As Sen. Jon Kyl, R-Ariz., acknowledged, repeal “is not realistic because Barack Obama would veto the bill and we don’t have the votes to override it.”
For Republicans such as Boehner, Kyl and DeMint, “repeal and replace” is an election strategy and not a practical legislative goal. ...
Repeal-and-replace Republicans eventually must face the difficult task of explaining why their apocalyptic predictions — everything from the death panels to the dismantling of democracy — didn’t come true. In the months and years to come, many Americans, even those skeptical about the reform effort, will come to see the scare tactics as hyperbolic depictions of a bill whose moderate approach incorporated many Republican ideas.
Republicans have just suffered a devastating legislative defeat, and they are entitled to nurse their wounds. But the GOP’s political aspirations — and the nation’s interests — would be best served by full engagement on the many critical issues facing Congress, from financial regulatory reform to immigration to unemployment. ... Republicans remain fixated on their loss on health reform — so much so that some, including Sen. John McCain, R-Ariz., have publicly ruled out any bipartisan cooperation for the remainder of the current session.
The American people need — and deserve — a legislative process in which both parties are engaged and bring competing views to the table. By clinging to the cold corpse of the health care debate, Republicans will miss an opportunity to express a clear, compelling vision on other issues — a vision that could do far more to sway voters to their side this fall than continuing to flail away over health care. ...
While there is still time, Republicans should repeal and replace their catchphrase, and substitute another that bodes better for their party’s future.

There's an inconsistency between free market ideology and the need for reform in areas like health care and financial services. One of the first steps in reforming the system is to acknowledge that the market won't take care of the problems itself. Once that is acknowledged, i.e. that regulation is needed to fix these market failures, the only question is whether that regulation will be of the "market-based" variety or by edict (e.g. this is the difference between system of tradable carbon permits that allow least cost carbon reduction strategies to emerge and a government set emission limit for each industry which generally does not achieve ca4rbon reductions at least cost).

With Democrats mostly opposed to old fashioned edict style regulation -- with their willingness to embrace market-based solutions to regulatory issues -- and with Republicans unwilling to embrace anything that Democrats propose, there is little ground left for those Republicans who are willing to admit that markets sometimes fail to stand upon. Democrats have taken the middle ground -- market based regulation -- from Republicans. This leaves Republicans with a choice of going along and compromising (and thereby embracing proposals they have made in the past, e.g. the health care bill looks an awful lot like the health care program Romney put in place in Massachusetts), or standing in opposition simply because it is a Democratic proposal. The choice they've made, standing in opposition to everything, is a losing strategy that allows policy to be shaped entirely be the other side. It will be interesting to see if a fissure develops within the Republican Party over this.

Will Republicans be able to share the market-based regulatory ground Democrats have taken away? There are already signs that Republicans will work with Democrats on financial reform, but there were early signs of a bi-partisan effort on health care as well, so we'll see how this plays out. I think people are fed up with banks and want something to be done, and Republican attempts to block legislation won't play well with the public at all. So I expect the coalition of no to be broken -- some legislators will see that they cannot continue just saying no and expect public support -- but not without big fights within the Republican Party between the extremists and the centrists. If Republicans do move in this direction, and it's more likely they'll do so on financial reform than on climate change legislation, you'll see an attempt to reclaim these policies as Republican (here's a great example: Health Care Reform--A Republican Idea?). And given the administration's centrist tendencies, in many cases they'll have a pretty good argument.

Posted by Mark Thoma on Saturday, March 27, 2010 at 10:34 AM in Economics, Financial System, Health Care, Politics, Regulation Reblog Permalink Comments (32)

Comments

roger said...

MT, you write about the Dems "willingness to embrace market-based solutions to regulatory issues" - I'd read that a little differently: with the Dems "unwillingness to embrace regulatory solutions to market-based problems."

That, I think, is a more accurate index of the Democratic party's conservatism.

howard said...

we can only hope that the gop will go all-in on repeal....

jrossi said...

This bill has lots of problems from where I sit. One comes to mind immediately: Medicaid reimbursements will increase for us primary care docs, but will be cut for specialists. This essentially turns the primary doc's office into a Community Health Center (poverty medicine clinic), where the primary is left holding the bag.

For example, suppose a Medicaid pt comes to my practice who needs immediate specialty care (draining a peri-tonsillar abscess, for example), but who will be unable to see one because none of the local ENT docs will take the risible payment. So I"m stuck, with an acutely ill pt that I can't help. Well, I could spend a hour on the phone begging someone to take him, or I could send the pt to the ER and move on to my next pt, so I can actually stay in business and keep my practice open. This kind of crap happens every single day in poverty medicine and is one of the main reasons why it can be so hellish to take care of people without adequate insurance. Begging the GI guy to see your rectal bleeder, begging the surgeon to see your hernia case, begging the neurologist to see your headache pt. Make no mistake about it, insurance that specialists refuse is inadequate. Better for mental health and, usually, the bottom line of the primary doc to refuse to take part.

Get to work on this, politicians of America.

OhNoNotAgain:

The big question is: are the Medicaid rates for specialists enough for them to make a profit and cover their costs ? If so, then I think these specialists are going to find themselves in a lot of trouble if they keep up the practice of refusing to see patients because the payments aren't as high as they want them to be.

jrossi:

That is a big question. Profit is total revenue minus total expenses. What you're really asking is whether the marginal cost of seeing a Medicaid pt is greater than the marginal revenue you get from seeing the pt. Well, it depends on the practice's variable cost structure, doesn't it?
Another interesting question is opportunity cost. If you can see a private pt at $200 and a Medicaid pt at $75, the choice is easy, if you can pick and choose.
Will the specialists be in a lot of trouble? Again, it depends. If I send the ENT 9 paying pts for every Medicaid one, he risks losing a lot of money by pissing me off and refusing to see my Medicaid pt. If I send 2 paying pts for every 8 Medicaiders, well, he might not care for my business.
The devil is in the details in HC reform.

anne:

J Rossi:

This bill has lots of problems from where I sit. One comes to mind immediately: Medicaid reimbursements will increase for us primary care docs, but will be cut for specialists. This essentially turns the primary doc's office into a Community Health Center (poverty medicine clinic), where the primary is left holding the bag.

For example, suppose a Medicaid pt comes to my practice who needs immediate specialty care (draining a peri-tonsillar abscess, for example), but who will be unable to see one because none of the local ENT docs will take the risible payment. So I"m stuck, with an acutely ill pt that I can't help. Well, I could spend a hour on the phone begging someone to take him, or I could send the pt to the ER and move on to my next pt, so I can actually stay in business and keep my practice open. This kind of crap happens every single day in poverty medicine and is one of the main reasons why it can be so hellish to take care of people without adequate insurance. Begging the GI guy to see your rectal bleeder, begging the surgeon to see your hernia case, begging the neurologist to see your headache pt. Make no mistake about it, insurance that specialists refuse is inadequate. Better for mental health and, usually, the bottom line of the primary doc to refuse to take part.

[I know, I know and this is quite important and especially worrisome since there are supposed to be further limits to physician payments to come and the limits are to be selective in terms of area of practice.]

Hal:

The GOP seems headless. One would think McCain would be the leader, but he is so weak and desperate he needs Palin to help him keep his senate seat. When Palin is the GOP's not so secret weapon you can be pretty sure the party is headless, or better, brainless. What is frightening is that brainless might win lots of votes in 2012 if Americans are still angry and uninformed.

anne:

J Rossi:

This bill has lots of problems from where I sit. One comes to mind immediately: Medicaid reimbursements will increase for us primary care docs, but will be cut for specialists. This essentially turns the primary doc's office into a Community Health Center (poverty medicine clinic), where the primary is left holding the bag....

http://www.nytimes.com/2010/03/26/health/policy/26docs.html

March 25, 2010

More Doctors Giving Up Private Practices
By GARDINER HARRIS

The delivery of medical care is changing as more young physicians take jobs with heath systems and older doctors sell their practices to those same systems.

[Also, the nature of what a community doctor is and how much leeway such a doctor may have is changing and seemingly quickly.]

alan :

There are a lot of strange distortions in the medical system right now - probably a lot to do with malpractice system. For example, I went to doctor to get finger stitched, was told I needed a surgeon and had to go to ER. All I got was 5 stitches! Maybe the primaries and nurse practitioners will have to get on with doing real care instead of referring, and maybe we'll have to figure out how to get the gun-for-hire lawyers to back off.

jrossi :

That's weird Alan. This family doc sews people up all the time, and so does my NP. You must live in the East or in a big city.

jrossi :

Anne, Independent family docs have been a dying breed for years, but now it's hitting the specialists--and quick. I don't know if it's good or bad. Interesting times.

Fred C. Dobbs:

I wonder, is there any other reason for this than specialists getting much better salaries?

It is true, apparently, that doctors are 'practicing differently' these days.

http://www.nytimes.com/2010/03/26/health/policy/26docs.html

NYT - March 25, 2010
More Doctors Giving Up Private Practices
By GARDINER HARRIS
WASHINGTON — A quiet revolution is transforming how medical care is delivered in this country, and it has very little to do with the sweeping health care legislation that President Obama just signed into law.

But it could have a big impact on that law’s chances for success.

Traditionally, American medicine has been largely a cottage industry. Most doctors cared for patients in small, privately owned clinics — sometimes in rooms adjoining their homes.

But an increasing share of young physicians, burdened by medical school debts and seeking regular hours, are deciding against opening private practices. Instead, they are accepting salaries at hospitals and health systems. And a growing number of older doctors — facing rising costs and fearing they will not be able to recruit junior partners — are selling their practices and moving into salaried jobs, too. ...

jrossi:

It's the money, Fred. If PCPs could make a reasonable living we would not group up much. Actually, a small single-specialty group is fine, mainly because you can share on-call and overhead, plus a lot of us like a small group--two or three heads are better than one. But most docs, myself included, would avoid multi-specialty groups, where PCPs are low men on the totem pole, and hospital or health system owned groups, where a@@holes in business suits call the shots. Most docs like to be independent. But you can't make much of a living doing this, so we are forced to group up. There's a recent post at Kevinmd about a doc worried about cuts in Medicare putting him out of business (he's an internist so he should be OK at least temporarily with the 10% increase), but the details of the doc's practice finances are interesting. Revenue 800k, Costs 720k, take home 80k. He shoulda gone to nursing school, probably would get paid more.

Fred C. Dobbs:

I think it's interesting that doc's like to be businessmen, get the revenues, don't like the costs, complain about the net. Forget nursing; go be a (salaried!) hospitalist. On the other hand, you guys are heroes & life-savers. Deal with it!

You want $$$, go be investors.

Zephyr:

The healthcare system is being choked by the pressures of the insurance system. Insurance is the biggest problem with our healthcare system. We need to remove the insurance bureaucracy from the healthcare dollar. This applies to government insurance and private insurance.

We need publicly funded clinics and hospitals available equally to all.

We have public roads, public defense, public schools...
...why not public healthcare?

Fred C. Dobbs:

Just 4 years ago, Mitt Romney was getting along wonderfully with the Democrat-controlled MA legislature, famously establishing universal health care (which was good enough to become the model for the US plan). Things were looking up for him and the Republicans, sort of. Then the election campaign of 2008 happened and the Republicans soiled themselves. The question has to be, can they swallow their pride, clean themselves up, and return to rational political discourse? The country sorely needs to have two functional parties, for balance if nothing else. It's not looking good, yet.

Fred C. Dobbs:

'Things were looking up for him and the Republicans, sort of': aside from a furious
urgency to get past the Bush Jr years a.s.a.p.

anne:

Alan:

"There are a lot of strange distortions in the medical system right now - probably a lot to do with malpractice system."

The effect of malpractice concerns has been repeatedly studied and found to have a minimal effect on health care cost. A sense of this is that by the beginning of 2005, there were already a majority of states with malpractice suit limits in effect and the difference has been minimal if any. Nonetheless, there is a sense that malpractice makes a difference in costs even among doctors even in states with the strictest limits such a Texas. This would seem quite wrong.

Fred C. Dobbs:

It's arguably effective that doctors would have us believe that they need high pay to cover their
malpractice premiums, even if it's only anecdotal.

anne:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

June 1, 2009

The Cost Conundrum: What a Texas town can teach us about health care.
By Atul Gawande

“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted....

Fred C. Dobbs:

Interesting , but as the article says:

'McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care.'

What does this 'teach us about health care'?
Don't do it like they do it in McAllen TX.

Fred C. Dobbs:

Even more interesting, the article says:

'The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.' ...

I believe I have read that this has to do with physician-entrepreneurs 'providing' (selling?) diagnostic testing to their patients. Very profitably too. Personally, I think testing is a great idea, when done ethically & cost-effectively.

Fred C. Dobbs:

By the way, many doctors think
'the world' of Atul Gawande, MD.
http://gawande.com/about
Brigham and Women’s Hospital
Department of Surgery
gawande@gawande.com,
etc.

Reality Bites:

The cap instituted in Texas is not the malpractice reform that was proposed and rejected. Notice that only pain and suffering is capped at $250,000. A doctor could still get sued for millions if he fails to test for an obscure ailment that eventually leads to a loss of function or life. Thus the need to practice defensive medicine.

Republicans aren't on board on this bill. Their proposals voiced during the "debate" with Obama were rejected. There's no reason why they should lend support to a bill they believe will be very harmful to the country and end up raising health care costs.

ken melvin said...

If there really was a god, those who keep on yapping about malpractice would be among those who got their brains fried and the letter of apology cause see MO has a $250k cap.

beezer said...

The 800 lb gorilla in the room is the doctors, or lack thereof.

We don't graduate enough physicians because it's pretty much financially out of reach for most of those smart and talented enough to compete. Too few of anything is going to raise labor rates.

Also, we've turned physicians into businesspeople first. Got to make that real big "nut." Not really the right focus for medical care overall, and certainly not for producing affordable care specifically.

Too many doctors today got there in order to become wealthy. And as long as that is the primary motivation, health care will always be far too expensive.

Open up education by subsidizing medical education so all the bright young ones can compete, in return for guaranteed salaries. We'll get a stronger corps of physicians overall, as well as physicians who have the right motivation to begin with.

History:

Per Uwe Reinhardt, who knows about these things, US medical costs are too high because we pay too much for things. (Not that McAllen-style overuse isn't a problem also). The things are:
1) Medical bureaucracy, i.e. insurance companies.
2) Drugs
3) Doctors, who are paid about twice what they are in the rest of the world relative to prevailing incomes.

Our gross overpayment per year (compared to other advanced countries) is about $1T/yr,
split $300B, $300B, $400B.

We're discussing point three. The main reason (along with what beezer correctly said) for this situation is that Lyndon Johnson bribed the AMA into letting him pass Medicare. The bribe took the form of allowing arbitrary pricing for new procedures, under the rubric "usual, customary, and reasonable". In this scenario a procedure might cost $50 and a somewhat improved one $5000. I actually saw one instance of this apparently absurdly exaggerated increase cited; although I'm too lazy to look it up.

The doctors who are highly paid are the ones who do procedures. Hence, a lot of procedures.

Cutting procedure reimbursement rates is indispensable to cutting costs. The solutions to monopoly-based price increases are: 1) regulation, or 2) monopony; you take our business because there is no other.

[Mar 29, 2010] Booming business helps patients navigate medicine - The Denver Post

By MIKE STOBBE AP Medical Writer Article Launched: 07/24/2008 12:21:20 PM MDT NORCROSS, Ga.—After three surgeries, Judy Sherer still had chronic pain in her left shoulder. She'd lost faith in her doctors, and in despair tried a new health benefit offered by her employer.

The service, Health Advocate, is a call-in center that helps customers find the right doctor, haggle over insurance coverage and manage other medical system headaches.

An advocate helped Sherer find a new surgeon—one who found metal shavings left in her shoulder by a previous doctor. The advocate also negotiated the charge for her physical therapy down to $40 per visit from the $200 she was told initially.

"It saved me a ton of money," said Sherer, 63, of Norcross, Ga. "I'm very, very pleased."

Health Advocate is one of a growing number of U.S. companies offering some form of advocacy services to medical consumers. Revolution Health—the Web-based medical consumer services company overseen by AOL co-founder Steve Case—has been considering getting into the same business.

"It's a really interesting industry that's just taking off," said Carol Fischer, a spokeswoman for Pennsylvania-based Health Advocate, a 12 million-member organization.

Currently, the health advocacy business is an industry with about $50 million to $75 million in annual revenue but only about a dozen companies of any significant size, said Richard Rakowski of Intersection LLC, a Connecticut-based investment and development firm that has researched the field.

But those numbers have grown from a few years ago, and it may be on track to become a $1 billion industry based on the demand for the service, said Rakowski, the firm's principal.

The field is blossoming in the wake of cutbacks in corporate health benefits, an overhaul of Medicare and other changes that have forced medical consumers to shop more for medical care.

More than ever, people need help negotiating the medical system, said Jessica Greene, a University of Oregon health policy analyst.

"We're asking consumers to make more complicated decisions, but the numeracy and health literacy skills of many consumers are not at the level needed to handle this new responsibility," Greene said.

Though some consumers are savvy enough to beat a billing overcharge or probe doctors' litigation histories, they don't have the time for such labors, experts said.

Indeed, the largest customers of health advocacy services are companies, not individuals. "The employers are interested because it means their employees are not on the phone taking care of doctor's visits" during work hours, Fischer said.

The companies grouped into the health advocacy business range from small regional firms operating out of home offices to companies with national call centers the size of football fields. No one seems to have an exact count, but Flagship Global Health, Care Counsel and Enhanced Care Solutions are among the more visible names.

Health Advocate claims to be the largest. Founded in 2001, it now has more than 3,500 companies, unions and other organizations as clients, including Johnson & Johnson, American Express and The Home Depot Inc.

Altogether, about 2.6 million employees, or members, are signed up with Health Advocate. But the number who can use it is actually higher: Members can share the call-in number with spouses, children, parents and parents-in-law—including elderly kin who need help picking a Medicare prescription drug plan, finding a nursing home or arranging transportation for health care. With all relatives added in, Health Advocate's membership as roughly 12 million, Fischer said.

About 180 advocates staff Health Advocate's call center in suburban Philadelphia. It's usually registered nurses who talk to the patients, and each patient gets an advocate who stays with the case and is the recurring contact. The staff also includes behind-the-scenes workers who help with insurance claims and other administrative questions.

"I'd say 80 percent of (our) people call Health Advocate because they have trouble with billing," said Andrew May, a human resources vice president for Wells Real Estate Funds, the Georgia-based company that employs Sherer.

Initially, May said, he doubted Wells employees would use Health Advocate, thinking they would instead continue to come down to human resources for help rather than turn to a 1-800 number.

But some of Wells' 400 employees started using it and having great experiences, he said. Company executives appreciated the help, calling the $5,700-a-year cost a good deal.

"We're not billing specialists. We're not registered nurses. To have that resource is much more powerful—it gets to the bottom of things quicker," said Susanna Johnson, a Wells human resources manager.

Health Advocate in May began to sell its services straight to individuals, as a $365-a-year service.

Some other companies have always focused on individuals, especially rich ones.

One example is $10,000-a-year PinnacleCare, founded in 2002 by John Hutchins, who created a concierge-like service at the Cleveland Clinic. He later used his connections to build a national network of doctors for his private health advisory start-up.

The Baltimore-based company is essentially a club for millionaires and billionaires that puts nurses and social workers in touch with members. Not only will they help members find top-level care, they will get them moved to the head of the line. PinnacleCare advisers will even meet the patient at a doctor's office or hospital.

PinnacleCare has about 1,700 member-families. One satisfied customer is Kirk Posmantur, 45, the founder and chairman of Axcess Luxury & Lifestyle. His Atlanta-based company markets handmade watches, private jets and other luxury items to the affluent.

"It's a no-brainer for those who've got net worth of $5 million or more," he said. "You've got people who advise you on your taxes. You've got people who advise you on how to manage your money. But what's more important than your health?"

Not every health advocacy group is a for-profit business.

The Patient Advocate Foundation provides free help to people with chronic, debilitating and life-threatening conditions. Founded in 1996, the Virginia-based organization has 113 employees and an annual budget of about $8.5 million. It handled nearly 45,000 cases in 2007—most of them cancer patients.

The organization's founders initially expected many clients to be uninsured. As it turns out, about 80 percent have at least some health insurance but are dealing with pre-approval authorizations, medical debt from incomplete coverage or other problems, said Nancy Davenport-Ennis, the group's chief executive and co-founder.

Companies like PinnacleCare are a blessing "for those consumers that can afford to have a boutique service," she said.

She wishes, however, that companies would provide more pro bono service. "The concern is those that need help and can't afford something like that," Davenport-Ennis said.