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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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[Mar 23, 2017] The difference between Obamacare and AHCA is 24 million uninsured people while the difference between single-payer and Obamacare is 28 million uninsured people

Mar 23, 2017 | economistsview.typepad.com
Peter K. : Reply Thursday, March 23, 2017 at 05:54 AM , March 23, 2017 at 05:54 AM
Reminds me of PGL, EMichael, "Anachronism" etc.

https://lbo-news.com/2017/03/22/never-demand/

Never Demand
by Doug Henwood
March 22, 2017

Matt Bruenig already wrote* about this (now deleted) tweet from Paul Waldman, which was a response to one from Bernie Sanders

Paul Waldman: Like saying "Never lose sight of the fact that our goal is to remodel the kitchen" when there are arsonists pouring gasoline on your porch."

Bernie Sanders: "Never lose sight of the fact that our ultimate goal is not just playing defense. Our goal is a Medicare-for-all, single payer system."

and before typing any more, I must confess to feeling guilty about writing a second blog post (god knows there are probably more) about a tweet. But, onwards.

As Bruenig writes, "The difference between Obamacare and AHCA is 24 million uninsured people while the difference between single-payer and Obamacare is 28 million uninsured people." Obamacare, with all its omissions and cost-shifting, isn't innocent of monstrousness.

There's a point about political strategy here worth drawing out here. Waldman, who self-identifies as "Washington Post blogger. Columnist for The Week. Senior Writer at the American Prospect.," was on the Cabalist, a secret listserv for liberal pundits which I strangely spent two or three years on. (I assume he still is, though I can't know now that I'm off the thing.) I was invited on, I suppose, for ideological diversity, but left as what most members probably saw as an annoying provocateur.

Waldman's tweet reflects a consensus on the list that one must never make demands or express ambitious political goals in the way Sanders' tweet does. All we can do it defend what we have, because the right holds all the cards. I never could convince them that this was a doomed strategy-that, principle aside, if you don't make big demands you can't win even small victories, or that without radicals pushing things in threatening ways their wimpy appeals to compromise will have no audience. To your modal Cabalister, to push for single-payer would be to "relitigate" (a favorite word of theirs, reflecting I suspect their preference for litigation over actual politics) Obamacare, and so expose it to repeal. That was their line a couple of years ago, when no one could have imagined President Trump. Now that it is under the threat of repeal, it's more urgent than ever to assume a defensive crouch.

You can see this sort of thinking behind the Democrats' responses to Trump. They're still stuck in the Hillary mode of treating him as an anomaly, something different from a "normal" Republican. They obsess about his alleged Russia ties, but offer nothing as a serious alternative to the Trump (or Ryan) agenda.

Obamacare has never been so popular now that it may go away. Millions of people have gotten something good out of it, as flawed as it is. Imagine how popular a program that offered everyone full coverage would be.

* https://medium.com/@MattBruenig/opponents-of-single-payer-are-moral-monsters-on-par-with-ahca-proponents-c6c152b18bd5#.2f52xubwb

JohnH -> Peter K.... , March 23, 2017 at 07:35 AM
Democrats play defense so much that occasionally they score on goals..handing victories to opponents because they could no effective offense of their own.

Imagine where Democrats could be if they deigned to talk to workers, actively pushed for higher minimum wages, and crafted a coherent economic message that spoke to "people who work hard and play by the rules."

Not going to happen: the corrupt, sclerotic Democratic leadership has grown comfy playing Washington General to Republicans' Harlem Globetrotter. They even refuse to sack a leadership who has lost most everything between the coasts.

Fortunately for them, we live in a duopoly, so there is always a place for the losing team.

RC AKA Darryl, Ron said in reply to JohnH... , March 23, 2017 at 08:19 AM
Yep.
im1dc -> JohnH... , March 23, 2017 at 08:57 AM
Dittos, and S. Sanders proved it last year. Why it is taking the current DEM leadership so long to put the lesson learned into action is beyond me and it angers me too.
RC AKA Darryl, Ron said in reply to Peter K.... , March 23, 2017 at 08:18 AM
Excellent article.
T : , March 23, 2017 at 06:12 AM
When the history is written, the Clinton Administration (and the Brad DeLongs in it) will be remembered for 4 things:

1) a massive increase in inequality carrying on the tradition began by Reagan;

2) incarcerating a large and increasing share of the black male population causing unfathomable damage to the black community;

3) passing a welfare reform package that was both cruel and unproductive to the least fortunate in our society;

4) negotiating and cheer-leading a Chinese trade deal that led to the loss of at least three million manufacturing jobs, primarily in the Midwest, and the destruction of community after community. And laying the seeds for those Democratic states to turn Republican.

Meanwhile Brad continues to let his "neoliberal freak flag fly."

painer -> T... , March 23, 2017 at 06:24 AM
Liberal consciences

Attend to this indictment

Peter K. -> T... , March 23, 2017 at 06:26 AM
So true. Also on macro policy he bent the knee to Greenspan/The Fed/the bond market, dumping his fiscal expansion campaign promise in exchange for deficit reduction.

Democrats have become all about deficit reduction and "the era of big government is over."

It is interesting to listen to David Beckworth's interview with Jason Furman who expresses the conventional thinking of Democrats.

Fiscal expansion is now good and desired within the context of the Zero Lower Bound and how unconventional monetary policy supposedly doesn't work.

But still they are okay with the Fed being paranoid about inflation, another legacy of the Clinton era.

Clinton did deliver a brief moment of a high-powered economy at the end of the 90s as Greenspan held off on raising rates.

But he also gave us the dot.com bubble with a push for deregulation, exemplified by repealing Glass-Steagall on behalf of the financial sector, the same people who would give us an epic financial crisis.

And Clinton was never big on union/organizing rights or anti-trust. He signed the Defense of Marriage Act etc etc etc.

But hey he was better than Republicans!

[Mar 23, 2017] Paradoxically, we appear to be seeing a coalescence and consolidation of insurers, we will end up being delightfully exceptional, again- effectively being single-payer, private sector, paying a monopoly an add-on cost of 35-40% to a parasitic industry whose executives and employees do not contribute to the CARE equation.

Notable quotes:
"... Why Steve Bannon Wants You to Believe in the Deep State" [Politico]. "Like the Death Star, the American Deep State does not, of course, exist. " ..."
Mar 23, 2017 | www.nakedcapitalism.com
djrichard , March 22, 2017 at 5:35 pm

Just a bit of a thought experiment, building on some thinking from a comment yesterday by jefemt

Paradoxically, we appear to be seeing a coalescence and consolidation of insurers, we will end up being delightfully exceptional, again- effectively being single-payer, private sector, paying a monopoly an add-on cost of 35-40% to a parasitic industry whose executives and employees do not contribute to the CARE equation.

Taking jefemt's thinking further, imagine the health insurance provider was not only monopolistic (owned the entire market), but was also a GSE (government sponsored enterprise). Now take it one more step and imagine it was an actual part of the government and not merely a GSE.

Conceivably, it wouldn't even have to live off appropriations from congress, assuming it was equally as extractive from the private sector as it is now (i.e. revenue model is the same). Talk about good living. Who knows, maybe they pocket their proceeds into some kind of surplus in Treasury dept.

But let's assume they had to give up on revenue models. [Afterall, it's easier to find partners in congress when you have an appropriations process that binds you to them.] Then they would be exposed. Somebody would get the bright idea that this agency doesn't need as much staffing since they are no longer revenue oriented. That indeed, they could have the same staffing profile as the agency responsible for medicare. Indeed they could be folded into medicare.

I was thinking of this too as a reponse to Why Steve Bannon Wants You to Believe in the Deep State" [Politico]. "Like the Death Star, the American Deep State does not, of course, exist. "

Indeed, I think of the insurance industry as being part of the deep state already. It seems that congress's preference is that this part of the deep state is outsourced. So that's it not a GSE, and not even a monopoly, but maintained as an oligopoly. And then, well hey whatever surplus it can hoover up is fair game. After all free-hand of the market and all that. [And heaven knows, we don't want to crowd that out.]

In contrast to other parts of the deep state that don't really have a revenue model. In which case, those parts need to be insourced by the Fed Gov.

human , March 22, 2017 at 7:46 pm

The CIA has a long history of drug trafficking. The FBI traffics in blackmail. The NSA in network surveillance. DIA, special ops. NRO, satelite throughput. 11 more in the US of A and countless more globally. They all have opaque resources outside of regular channels.

Ernesto Lyon , March 23, 2017 at 12:09 am

Great documentary about the 80's cocaine business in Miami called "Cocaine Cowboys." It's real life Scarface.

Guess who the Feds sent to get a handle on the cocaine smuggling?

See-eye-aye man George H.W. Bush. Coincidence?

[Mar 22, 2017] Medicaid is a popular and relatively efficient insurance program that has provided health care and peace of mind for millions of Americans for more than half a century. Why start taking it apart now? Because that is the genes of neoliberalism. A wolf cant stop hunting. This is a predatory ideology

Notable quotes:
"... Obamacare, President Donald Trump is fond of saying, is a "complete and total disaster" and must be replaced. Yet one of the most significant features of his party's proposed replacement has little to do with Obamacare. ..."
"... True, expanded eligibility for Medicaid is an important part of Obamacare. And the AHCA would reverse this expansion. But its much bigger change is to the Medicaid program as it existed long before Obamacare. Medicaid is a popular and relatively efficient insurance program that has provided health care and peace of mind for millions of Americans for more than half a century. Why start taking it apart now? ..."
"... Whatever the reason, it's a step in the wrong direction. Those who lose Medicaid coverage would still need care, and their fellow Americans would still have to pick up the tab. ..."
"... As things stand now with Medicaid, states pay doctors for providing care to enrollees, and the federal government reimburses the states up to 75 percent of that cost. When a state spends more than usual -- in the event of a hurricane or an opioid epidemic, for example -- the federal share keeps up. ..."
Mar 22, 2017 | economistsview.typepad.com
Anachronism : March 22, 2017 at 10:55 AM
https://www.bloomberg.com/view/articles/2017-03-22/republicans-want-to-repeal-medicaid-too

Republicans Want to Repeal Medicaid, Too

Obamacare, President Donald Trump is fond of saying, is a "complete and total disaster" and must be replaced. Yet one of the most significant features of his party's proposed replacement has little to do with Obamacare.

The American Health Care Act would drastically reshape Medicaid -- ending the federal government's long-running, open-ended commitment to help states pay for care for the poor. Instead, in 2020, Washington would make limited per capita contributions that would shrink as a share of costs with every passing year.

True, expanded eligibility for Medicaid is an important part of Obamacare. And the AHCA would reverse this expansion. But its much bigger change is to the Medicaid program as it existed long before Obamacare. Medicaid is a popular and relatively efficient insurance program that has provided health care and peace of mind for millions of Americans for more than half a century. Why start taking it apart now?

Part of the rationale is that the changes to Medicaid would save $880 billion over 10 years, allowing Congress to make further tax cuts later this year. (Trump telegraphed the strategy in a speech to supporters Monday.) At the same time, many Republicans have long disliked the program's open-ended promise of federal money.

Whatever the reason, it's a step in the wrong direction. Those who lose Medicaid coverage would still need care, and their fellow Americans would still have to pick up the tab.

As things stand now with Medicaid, states pay doctors for providing care to enrollees, and the federal government reimburses the states up to 75 percent of that cost. When a state spends more than usual -- in the event of a hurricane or an opioid epidemic, for example -- the federal share keeps up.

Under the AHCA, each state would instead be given a capped allowance, and that amount would rise each year with medical inflation. It would not account for any unforeseen expenses. Over time, as the rise in per-patient costs outstripped the rise in general medical inflation -- as the Congressional Budget Office assumes they will -- the federal share of funding would decline. Hundreds of billions in costs would be shifted from the federal government to the states. In response, states would need to either raise their own spending on Medicaid -- or more likely, offer fewer services to fewer people.

It is this last possibility that is most disturbing. Medicaid has been required to cover some groups of people -- mothers and children living in poverty, for example -- but not all. One of the consequences of the AHCA would be to discontinue coverage to many who just recently gained coverage under the expansion funded by Obamacare. If a state took the option, now included in the AHCA, to accept a Medicaid block grant rather than a per-capita allotment, it could set its own eligibility standards.

Sending large groups of people back to the private insurance market in a post-Obamacare world, with its increasingly unaffordable premiums and increasingly expensive out-of-pocket costs, would be not only inefficient but also unjust.

libezkova -> Anachronism ... , March 22, 2017 at 05:09 PM
"Medicaid is a popular and relatively efficient insurance program that has provided health care and peace of mind for millions of Americans for more than half a century. Why start taking it apart now?"

Because that is the genes of neoliberalism. A wolf can't stop hunting. This is a predatory ideology. And that creates the seeds of it own demise, despite being pretty resilient after 2008 crash.

[Mar 22, 2017] The Men Who Stole the World

Notable quotes:
"... History will look back at us with the same wonder that we look back on the mad excesses of certain nations founded in devotion to extreme, almost other-worldly, ideologies of the last century. ..."
"... Apparently the slashing of health benefits for the unfortunate is not severe enough in the proposed Trump/Ryan plan. Our GOP house neo-liberals are enthusiastic to unleash the wonders of the cure-all deregulated market on the American public, again. Like a dog returns to its vomit. ..."
Mar 22, 2017 | jessescrossroadscafe.blogspot.com
"The problem of the last three decades is not the 'vicissitudes of the marketplace,' but rather deliberate actions by the government to redistribute income from the rest of us to the one percent. This pattern of government action shows up in all areas of government policy."

Dean Baker

"When the modern corporation acquires power over markets, power in the community, power over the state and power over belief, it is a political instrument, different in degree but not in kind from the state itself. To hold otherwise - to deny the political character of the modern corporation - is not merely to avoid the reality.

It is to disguise the reality. The victims of that disguise are those we instruct in error."

John Kenneth Galbraith

And unfortunately the working class victims of that disguise are going to be receiving the consequences of their folly, and then some.

Secure in their monopolies and key positions with regard to reform and the law, the corporations are further acquiring access to the protections of the rights of individuals as well, it appears, at least according to Citizens United .

Maybe our leaders and their self-proclaimed technocrats will finally do the right thing. I personally doubt it, except that if they do it will probably be by accident.

More likely, the right thing will eventually come about the old-fashioned way- under the duress of a crisis, and the growing protests of the much neglected and long suffering.

History will look back at us with the same wonder that we look back on the mad excesses of certain nations founded in devotion to extreme, almost other-worldly, ideologies of the last century.

... ... ...

Apparently the slashing of health benefits for the unfortunate is not severe enough in the proposed Trump/Ryan plan. Our GOP house neo-liberals are enthusiastic to unleash the wonders of the cure-all deregulated market on the American public, again. Like a dog returns to its vomit.

Better if they start breaking up corporate health monopolies and embrace real reform at the sources of the soaring costs. The US pays far, far too much for drugs and healthcare, and deregulating the markets is not the solution. We do have the example of the rest of the developed world for what to do about this. It is called 'single payer.'

But players keep on playing. And politicians and their enablers in the professions will not see what their big money donors do not wish them to see. And that is one of their few bipartisan efforts.

Might one suggest that our political animals stop trying to do all the reforming and cost controls bottom up, while applying the stimulus top down? That approach they have been flogging to no avail for about thirty years is a recipe for a dying middle class.

Here is a short video from the Bernie Sanders WV town hall that shows The Face of American Desperation. By the way, the governor of West Virginia is a Democrat. He wasn't there.

...

[Mar 21, 2017] Trump healthcare plan means less in income taxes on the rich and more in sales taxes for the rest of us

Mar 21, 2017 | economistsview.typepad.com
Peter K. -> pgl... March 20, 2017 at 06:37 AM , 2017 at 06:37 AM
"It means less in income taxes on the rich and more in sales taxes for the rest of us."

Nah glibertarians are against the sales tax because they see how it has increased in Europe and led to bigger government. That's why they're opposing Paul Ryan's tax reform which includes progressive wage subsidies.

pgl -> Peter K.... , March 20, 2017 at 09:45 AM
You must not get Paul Ryan. He wants a smaller government paid for exclusively by sales taxes. His agenda is to eliminate all taxes on capital income. FYI - Europe still has rather high profits taxes. Ryan's latest would end that for the US.
ken melvin -> anne... , -1
Congress critters from red states are demanding that people must have a job bin order to qualify for medicaid. In red states, most jobs don't pay enough to afford health care.

Explained to an environmental class the other day how it was that before EPA people knowingly (and unknowingly) took hazardous jobs in order to make a living -- a trade off. This is where these guys are headed.

Peter K. -> anne... , March 20, 2017 at 09:01 AM
http://cepr.net/blogs/beat-the-press/paul-krugman-and-the-republican-corporate-income-tax-proposal

Paul Krugman and the Republican Corporate Income Tax Proposal

by Dean Baker

Published: 28 January 2017

The current corporate income tax is a massive cesspool. There are so many routes for avoidance that it is almost becoming voluntary. This matters not only because we don't get the revenue we should from the tax, but also because it has created a massive tax avoidance industry.

The tax avoidance industry is a big deal. This is an industry that contributes nothing to the economy. It involves people designing clever tricks to allow corporations to avoid paying their share of taxes.

The tax avoidance industry is also an important source of inequality since it is possible to get very rich designing clever ways to avoid taxes. My colleague Eileen Appelbaum (along with Rose Batt) show how the private equity industry is largely a tax avoidance industry in their recent book Private Equity at Work. Many of the very richest people in the country got their wealth as private equity fund partners.

In his movie, Capitalism: A Love Story, Michael Moore highlighted "dead peasant" insurance policies. This is when a major company like Walmart buys life insurance policies on tens of thousands of front line workers, like checkout clerks. Usually the insuree doesn't even know of the existence of the policy, but if they die, the company collects.

Moore emphasized the morbid nature of this game, but missed the real story. The point of these policies is to smooth profits, partly to manipulate share prices, but also for tax purposes. The real highlight of this story is that there is someone who likely got very rich by developing dead peasant insurance policies, rather than contributing anything productive to the economy.

I mention this as background to the corporate income tax discussion since to my view a major goal of corporate tax reform is to eliminate the enormous opportunities for gaming that currently exist. These opportunities are making some people very rich and are a complete waste from an economic standpoint.


For this reason, I am sympathetic to the plan the Republicans are debating. In its conception it would be enormous simplification relative to the current system. Of course, that is the conception, we will have to see the plan as it is drafted in legislation to reach any final judgement.

In this vein, I have been unhappy to see some of the attacks leveled by people for whom I have considerable respect, notably Paul Krugman. In a post yesterday, Krugman makes the case that the basic tax proposal would be a subsidy for domestic production and therefore inconsistent with free trade principles.

While I don't disagree with the logic, I question its importance. He contrasts the border adjustment with the Republican tax proposal with the border adjustment with a traditional value-added tax (VAT), pointing out that the latter doesn't give a domestic production subsidy in the same way. There are two important points left out of Krugman's discussion.

The first is the issue of size. VATs in our trading partners typically raise well over ten percent of GDP in revenue and sometimes more than 20 percent. By contrast, the corporate income tax has raised less than 1.7 percent of GDP in recent years. The Republicans are undoubtedly looking to reduce this amount further in their tax reform (hopefully they will not succeed), but the imposition of a tax equal to 15 percent of GDP matters much more for trade than a tax equal to 1.7 percent of GDP. (Suppose the dollar falls or rises by 1.7 percent in a week, as it often does. This has the same impact.)

The second issue is the point of reference. We don't currently have a VAT in the United States. We have various taxes that are assessed in the production process, including the income tax workers pay on their wages, that get passed on in the price of the product. If we snapped our fingers and replaced the income tax with a value added tax, we would then refund this tax on exported products. That would look like an export subsidy, relative to our current system. Similarly, we would slap the VAT on all items that are imported. That would look like an import tariff, relative to our current system.

Conventionally, economists urge us not to worry about this issue, since changes in currency values will even things out. This is probably true, at least over the long-run, if not immediately in a transition process. This is a situation where we should accept the economists' conventional wisdom on the net effect on trade, remembering that the amount at stake as an export subsidy or import tariff is just not that large in any case.

The Republican tax proposal, when it is actually put on the table, should be evaluated based on the extent to which it eliminates the waste associated with the tax avoidance industry and also for the amount of revenue it raises. Arguing for its rejection based on it being an unfair subsidy for domestic production is just silly.

There are plenty of very real reasons not to like the things Republicans are putting forward in the Trump administration. We don't have to invent fake ones.

Peter K. -> anne... , March 20, 2017 at 09:01 AM
http://cepr.net/blogs/beat-the-press/washington-post-pushed-fear-on-corporate-tax-reform

Washington Post Pushed Fear on Corporate Tax Reform
by Dean Baker
Published: 29 January 2017

The headline warned readers that the Republican's proposal for reforming the corporate income tax is coming for your toys, literally:

"Trump-era tax reform could come for your toys."
Okay, we get it. The Washington Post doesn't like the tax reform and is not content to keep its views to the opinion pages. (This article ran at the top of the Sunday business section.)

The basic story is almost Trumpian in its unreality. The tax reform includes a border adjustment tax on imports. This is similar (not identical) to what countries with value-added taxes do, which is almost every other wealthy country. The conventional wisdom among economists is that currencies adjust so that the net effect on the price of imports, including toys, is minimal.

While this piece notes this argument, it implies that consumers and retailers have great cause for concern over the tax. In this respect, it is worth pointing out that currencies fluctuate by large amounts all the time, in ways that are likely to have far more impact on the price of imported toys than this tax. The figure below shows the inflation-adjusted value of the dollar measured against the currencies of our major trading partners.

fredgraph10

Note that the dollar fell by more than 25 percent against the currencies of our major trading partners in the years between its peak in 2002 and its trough in 2008. This would have sent the price of imported toys up by far more than the new tax possibly could, even though it never prompted an article in the Post warning readers that a falling dollar was coming for their toys.

As a practical matter, a currency adjustment will take time and may not be complete, but in the technical language of economists, so what? If the price of imported toys rises by 3–4 percent as a result of the tax, what would be the big deal. This change is swamped by movements in currency values that never even get mentioned. (I discuss the tax reform proposal, which could get rid of the tax avoidance industry, at more length here.)

It is also worth pointing out that incredible hypocrisy and/or ignorance underlying these discussions. If the United States is to get back to something closer to balanced trade, as opposed to having a trade deficit of more than $500 billion (around 2.7 percent of GDP), it is likely to require a lower valued dollar and higher import prices.

We can count on news outlets like the Post pointing out that the higher import prices mean that lower income people will have to pay more for imported goods at Walmart. This is true, but they are also more likely to be able to get relatively good paying jobs in manufacturing. Also, the availability of these jobs is likely to put upward pressure on the wages of less-educated workers more generally. The net effect for these people is almost certain to be positive.

If this is hard to understand, suppose we remove the protectionist barriers that allow our doctors to earn twice as much as doctors in other wealthy countries. This would likely cause the pay of our doctors to be more in line with pay in Europe and Canada (@ $150,000 a year, as opposed to an average of more than $250,000 a year now). The doctors would all benefit because they and their families would now pay less for their health care, or at least this is how it would be covered using the Washington Post standard.

[Mar 21, 2017] Why No One Is Taking Robert Samuelson's Medicaid Deal Seriously

Mar 21, 2017 | economistsview.typepad.com
anne : March 20, 2017 at 05:50 AM , 2017 at 05:50 AM
http://cepr.net/blogs/beat-the-press/why-no-one-is-taking-robert-samuelson-s-medicaid-deal-seriously

March 20, 2017

Why No One Is Taking Robert Samuelson's Medicaid Deal Seriously

Robert Samuelson put forward what would ordinarily be a very reasonable proposal on Medicaid and Medicare in his column * today. He suggested that the federal government take over the portion of Medicaid that deals with low-income elderly and fold it into the Medicare program, while leaving states with full responsibility for dealing with the part of Medicaid that deals with low-income families below retirement age.

While he is right that this sort of consolidation could likely reduce costs and prevent seniors from falling between the cracks in the two systems, there is a basic problem with turning Medicaid over to the states. There are a number of states controlled by Republicans where there is little or no interest in providing health care for low income families.

This means that if Medicaid were turned completely over to the states, millions of low income families would lose access to health care. For this reason, people who want to see low income families get health care, which is the purpose of Medicaid, want to see the program remain partly under the federal government's control.

* https://www.washingtonpost.com/opinions/medicaid-is-out-of-control-heres-how-to-fix-it/2017/03/19/05167e9e-0b2e-11e7-a15f-a58d4a988474_story.html

-- Dean Baker

pgl -> anne... , March 20, 2017 at 06:04 AM
"There are a number of states controlled by Republicans where there is little or no interest in providing health care for low income families. This means that if Medicaid were turned completely over to the states, millions of low income families would lose access to health care."

Dean Baker is right to go after this idea from Robert (no relationship to Paul) Samuelson but two additional comments.

(1) This is really the Paul Ryan agenda.

(2) For states like mine that will take care of these low income families, this Ryan agenda does not mean less in taxes. It means less in income taxes on the rich and more in sales taxes for the rest of us. The ultimate Paul Ryan agenda.

Anachronism said in reply to pgl... , March 20, 2017 at 06:56 AM
There are 2 theories about how to argue with a republican. Neither one works.

What they care about is "lessez faire", which means low income families should die off from lack of healthcare. If they deserved healthcare, they should have been able to afford it themselves.

RC AKA Darryl, Ron said in reply to Anachronism ... , March 20, 2017 at 07:16 AM
If God had wanted poor people to have healthcare then he would have made them be born rich :<)
pgl -> Anachronism ... , March 20, 2017 at 09:43 AM
I might ask what those two theories are but I suspect you are right about neither one of them working.

[Mar 20, 2017] Reply

Mar 20, 2017 | onclick="TPConnect.blogside.reply('6a00d83451b33869e201b7c8e235d6970b'); return false;" href="javascript:void 0">
Monday, March 20, 2017 at 01:54 AM ken melvin said in reply to mulp... Let them eat ideology. Reply Monday, March 20, 2017 at 04:25 AM RC AKA Darryl, Ron said in reply to mulp... "...TANSTAAFL"

https://en.wikipedia.org/wiki/There_ain%27t_no_such_thing_as_a_free_lunch

"There ain't no such thing as a free lunch" (alternatively, "There is no such thing as a free lunch" or other variants) is a popular adage communicating the idea that it is impossible to get something for nothing. The acronyms TANSTAAFL, TINSTAAFL, and TNSTAAFL, are also used. Uses of the phrase dating back to the 1930s and 1940s have been found, but the phrase's first appearance is unknown.[1] The "free lunch" in the saying refers to the nineteenth-century practice in American bars of offering a "free lunch" in order to entice drinking customers.

The phrase and the acronym are central to Robert Heinlein's 1966 science-fiction novel The Moon Is a Harsh Mistress, which helped popularize it.[2][3] The free-market economist Milton Friedman also popularized the phrase[1] by using it as the title of a 1975 book,[4] and it is used in economics literature to describe opportunity cost.[5] Campbell McConnell writes that the idea is "at the core of economics".


[I was a bigger fan of Robert Heinlein's than I was of Milton Friedman and even then it was "Stranger in a Strange Land" and "The Unpleasant Profession of Jonathan Hoag" rather than later works that appealed to me.]
Reply Monday, March 20, 2017 at 04:59 AM ken melvin said in reply to mulp... She ate his lunch
http://crooksandliars.com/2017/03/joy-reid-destroys-lawmakers-medicaid-fear Reply Monday, March 20, 2017 at 05:08 AM pgl said in reply to ken melvin... "Appearing on Reid's Sunday morning program, Carter immediately got off to a rocky start after the MSNBC host asked how Georgia would be "better off" with nearly 500,000 people losing their Obamacare coverage."

Buddy Carter wasn't prepared. Joy Reid was. Thanks for the link. Reply Monday, March 20, 2017 at 05:44 AM Helicopter Appraisal Rules said in reply to mulp... kinds of medical treatments everyone expects insurance to pay for, like injuries from accidents, gunshots, child birth, premature birth neonatal care,
"

Insurance is a private matter unless subsidized. What inflation payers and taxpayers should never be forced to subsidize are childbirth and neonatal care. We shouldn't pay for what we have too much of already. Hell!

With global famine looming later this year and workers losing jobs to robotics, the last thing we need is more birth. Did Jean-Paul Sartre once quip, "Here is my definition of hell :

other people
"
?

No! He never learned to speak English. Or

did
he
?
Reply Monday, March 20, 2017 at 08:24 AM

[Mar 20, 2017] The Fake Freedom of American

Mar 20, 2017 | economistsview.typepad.com
Fred C. Dobbs : March 19, 2017 at 06:07 AM , 2017 at 06:07 AM
'If you really want to free Americans and unburden
American employers, why not try, or at least seriously consider, some form of government-managed health care,
like almost every other capitalist democracy? There
are many ways of giving people choice and excellent
care under government management. Universal publicly
managed health coverage would even free America's corporations and businesses to streamline their
operations, releasing them from bureaucratic
obligations that ... look weirdly socialist.
Would this mean they would have to pay
more in taxes? Possibly.'

(Not 'Possibly'. Inevitably. So be it.)

The Fake Freedom of American
Health Care https://nyti.ms/2nDNgAm
NYT - ANU PARTANEN - MARCH 18, 2017

Last week the nonpartisan Congressional Budget Office estimated that the new Republican health plan would increase the number of uninsured Americans by 24 million people within a decade, mostly because changes in regulations, subsidies and Medicaid coverage would make insurance too expensive for them.

Republican leaders seem unfazed by this, perhaps because, in their minds, deciding not to have health care because it's too expensive is an exercise of individual free will. As Representative Jason Chaffetz, Republican of Utah, put it: "Americans have choices. And they've got to make a choice. And so maybe, rather than getting that new iPhone that they just love, and they want to go spend hundreds of dollars on that, maybe they should invest in their own health care."

There is an appealing logic to such thinking. The idea is that buying health care is like buying anything else. The United States is home to some of the world's best medical schools, doctors, research institutes and hospitals, and if you have the money for the coverage and procedures you want, you absolutely can get top-notch care. This approach might result in extreme inequalities and it might be expensive, but it definitely buys you the best medical treatment anywhere. Such is the cost of freedom. As House Speaker Paul Ryan put it in a tweet: "Freedom is the ability to buy what you want to fit what you need." Vice President Mike Pence picked up that baton: "Obamacare will be replaced with something that actually works - bringing freedom and individual responsibility back to American health care."

In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money, but also time and energy agonizing over the bewildering logistics of coverage and treatment - confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices. And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost.

And I haven't even mentioned the millions of Americans who don't earn enough to pay for insurance or a lifesaving treatment. If you can't afford it, not buying it is hardly a choice.

Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system. Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes - which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City - and if I needed to see a doctor, I had several options.

For minor medical matters, I could visit a private physician who was provided as a perk by my employer. Or I could call the public clinic closest to my home. If I saw the private doctor, my employer picked up the tab, with the help of public subsidies. If I went to the public clinic, it might cost me a small co-payment, usually around $20. Had I been pregnant, most care would have been free.

If I had wanted to, I also could have easily paid to see a private doctor on my own, again with the help of public subsidies. All of this works without anyone ever having to sign up for or buy health insurance unless he wants additional coverage. I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.

Republicans are fond of criticizing this sort of European-style health care. President Trump has called Canada's national health care system "catastrophic." On CNN recently, Senator Ted Cruz gave multiple examples of how patients in countries with universal, government-managed health care get less care than Americans.

In Europe, he said, elderly people facing life-threatening diseases are often placed in palliative care and essentially told it's their time to go. According to the Republican orthodoxy, government always takes away not only people's freedom to choose their doctor, but also their doctor's ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.

But are Republicans right about this? Practically every wealthy capitalist democracy in the world has decided that some form of government-managed universal health care is the most sensible and effective option. According to the latest report of the O.E.C.D. - an organization of mostly wealthy nations - the United States as a whole does not actually outshine other countries in the quality of care.

In fact, the United States has shorter life expectancy, higher infant mortality and fewer doctors per capita than most other developed countries. When it comes to outcomes in some illnesses, including cancer, the United States does have some of the best survival rates in the world - but that's barely ahead of, or even slightly behind, the equivalent survival rates in other developed countries. In breast cancer survival, for example, the United States comes in second, after Sweden. Third-best is Norway, then Finland. All three countries have universal, government-run health care systems.

For colorectal cancer, the five-year survival rate after diagnosis in the United States brings it to a not very impressive ninth place in the O.E.C.D. statistics. Ahead of the United States are South Korea, Israel, Australia, Sweden and Finland, all with some form of government-managed universal health care. And when it comes to cervical cancer, American women are at a significant disadvantage: The United States comes in only 22nd. Meanwhile, life expectancy at age 65 is higher in 24 other developed nations, including Canada, Britain and most European nations.

Americans might still assume that long waits for care are inevitable in a health care system run by the government. But that's not necessarily the case either. A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That's a great achievement. But the Netherlands and Switzerland did better. When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.

It's not just American patients who endure endless bureaucratic hassles. American doctors were also significantly more likely to report as major problems the amount of time they spent on dealing with administrative burdens related to insurance and claims, as well as on getting patients medications or treatment because of restrictions imposed by insurance companies, compared with doctors in most of the other 10 countries studied - including Sweden and Britain.

Overall, Americans spend far more of their hard-earned money on health care than citizens of any other country, by a very wide margin. This means that it is in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.

The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one's life. It's also not like buying some other service tailored to individual demands, because for the most part we can't predict our future health care needs.

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone.

What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven't even been seriously sick or injured yet.

As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.

So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.

Here is my appeal to Republicans: If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free America's corporations and businesses to streamline their operations, releasing them from bureaucratic obligations that to me, coming from Finland, I have to say look weirdly socialist. Would this mean they would have to pay more in taxes? Possibly.

Many countries require employers and employees to contribute to the health care system through payroll taxes, more than the United States does. But again, Americans are paying far more for health care than anyone else, and America's businesses are stuck managing this mess. It's true that in countries with universal health care the cost of hiring a new employee can be significant, especially for a small employer. Yet these countries still have plenty of thriving businesses, with lower administrative burdens. It can be done.

In wealthy capitalist democracies all around the world the government itself also has an essential kind of freedom. It's a freedom that enables the government to do work on behalf of the citizens who elect it, including negotiating the prices of health care with providers and pharmaceutical companies - a policy that has led to lower drug prices in those countries.

Americans today are paying vastly more in money, worry and hassle for the same, and sometimes worse, care than people in other wealthy capitalist democracies. Some Americans have coverage that serves them well, but judging by the current mood, the number of Americans who think the system needs to change is growing. No health care system is perfect. But in a nation that purports to champion freedom, the outdated disaster that is the United States health care system is taking that freedom away.

[Mar 16, 2017] Arrow said it decades ago, the market does not work for health care. The Brits have known it since WW II or before.

Mar 16, 2017 | economistsview.typepad.com
RGC -> anne... March 14, 2017 at 04:11 AM , 2017 at 04:11 AM
Western politicians and mainstream economists have the same game plan:


Given choice 1 and choice 2....

Republicans choose 1a Democrats choose 1b

Neoliberals choose 1a Neo classicals choose 1b

1a is "hard" laissez-faire

1b is "soft" laissez-faire

2 is democratic socialism

anne -> RGC... , March 14, 2017 at 05:10 AM
Clever, and worth developing as a complete argument.
ilsm -> anne... , March 14, 2017 at 05:19 AM
Arrow said it decades ago, the market does not work for health care. The Brits have known it since WW II or before.
anne -> ilsm... , March 14, 2017 at 07:04 AM
https://en.wikipedia.org/wiki/National_Health_Service

The National Health Service (NHS) is the name of the public health services of England, Scotland and Wales, and is commonly used to refer to those of Northern Ireland. They were established together as one of the major social reforms following the Second World War on the founding principles of being comprehensive, universal and free at the point of delivery. Today, each provides a comprehensive range of health services, the vast majority of which are free for people ordinarily resident in the United Kingdom.

Taken together, the four National Health Services in 2015-16 employed around 1.6 million people with a combined budget of £136.7 billion. UK residents are not charged for most medical treatment, with exceptions such as a fixed charge for prescriptions; dental treatment is administered differently, with standard charges for most procedures. For non-residents, the NHS is free at the time of use, for general practitioner (GP) and emergency treatment not including admission to hospital.

The NHS began on the 'Appointed Day' of 5 July 1948.

[Mar 16, 2017] Health Care and Market Based "Solutions"

Mar 16, 2017 | economistsview.typepad.com
anne : March 14, 2017 at 03:26 AM , 2017 at 03:26 AM
http://econospeak.blogspot.com/2017/03/health-care-and-market-based-solutions.htm

March 13, 2017

Health Care and Market Based "Solutions"

The opening of a critique of TrumpDoesn'tCare by John Osborne has this canard:

"The excerpts are interesting, not because there were stunning disclosures or revolutionary ideas, but to the contrary they reveal what many have been saying for some time: there is no plan that will enable the Republican Congress to effectively replace Obamacare by relying solely on conservative, market-based solutions...at least not without risking great disruption to an already skittish insurance market."

The canard is that conservatives have some "market based solution". This begs solution to what? I wonder if these conservatives have read the 1983 paper by John Moskop ?:

"This paper considers whether Rawls' theory of justice as fairness may be used to justify a human right to health care. Though Rawls himself does not discuss health care, other writers have applied Rawls' theory to the provision of health care. Ronald Green argues that contractors in the original position would establish a basic right to health care."

While Moskop does not entirely agree with Ronald Green, many of us see the health care debate as one of basic fairness – not just efficiency....

-- ProGrowthLiberal

pgl -> pgl... , March 14, 2017 at 04:24 AM
Check out the subtitle:

'A total of 54 million individuals would be uninsured in 2026 under the GOP plan, according to the White House analysis.'

So the TrumpCare proposal will double the number of uninsured. In relative terms, about 8% of the population would be without insurance. Under TrumpCare - make that 16%. We need an improvement of ObamaCare. This is the opposite.

JF -> pgl... , March 14, 2017 at 06:21 AM
Pgl, ok to talk about an insurance solution but can you also mention healthcare itself?

People care about their health when confronted with it, few care about insurance organizations. The discussion, as I think you'd agree, needs to be more about health and public-health (a societal level view, considering many years). It is not a good debate to just talk about insurance and insurance contracts/plans.

pgl -> JF... , March 14, 2017 at 07:01 AM
In my latest at Econospeak I did talk about ending the doctor cartel as well as the pharma cartel. You are right - the real reason we pay too much for health care are the economic rents reaped by the providers.
JF -> pgl... , March 14, 2017 at 07:32 AM
Alignments of incentives a la Arrow. Healthcare delivery system is not a place where ideal free markets can arise, as most know, it just is not possible from the nature of the service itself.

Now few markets ever attain the ideal, of course. This is one of the reasons why the republicans talk mostly about insurance, here market verbiage has more traction. But these are 'financial' insurance products, they are not healthcare. As we know, you only insure your finances if you have something financial at risk. Most young people and families, and many others are not looking to insure their finances, they do need healthcare, however.

Society's need is to have a rational healthcare delivery system. Subsidization of a financial insurance industry is no where close to being equivalent.

Know you know this. Would want journalists and analysts to know this and write accordingly.

pgl -> JF... , -1
"Society's need is to have a rational healthcare delivery system. Subsidization of a financial insurance industry is no where close to being equivalent."

Agreed. So much time on how to pay for it but almost no time on how health care is delivered. Both are important topics.

Anachronism : , March 14, 2017 at 05:03 AM
With apologies to Anne, the article simply won't copy paste. You'll have to read it.

The title is: No easy answers: why left wing economics is not the answer to right wing populism

http://www.vox.com/world/2017/3/13/14698812/bernie-trump-corbyn-left-wing-populism

anne -> Anachronism ... , March 14, 2017 at 05:17 AM
http://www.vox.com/world/2017/3/13/14698812/bernie-trump-corbyn-left-wing-populism

March 13, 2017

No easy answers: why left-wing economics is not the answer to right-wing populism
By Zack Beauchamp

On November 20, less than two weeks after Donald Trump's upset win, Bernie Sanders strode onto a stage at Boston's Berklee Performance Center to give the sold-out audience his thoughts on what had gone so disastrously wrong for the Democratic Party.

Sanders had a simple answer. Democrats, he said, needed to field candidates who would unapologetically promise that they would be willing "to stand up with the working class of this country and ... take on big-money interests."

Democrats, in other words, would only be able to defeat Trump and others like him if they adopted an anti-corporate, unabashedly left-wing policy agenda. The answer to Trump's right-wing populism, Sanders argued, was for the left to develop a populism of its own.

That's a belief widely shared among progressives around the world. A legion of commentators and politicians, most prominently in the United States but also in Europe, have argued that center-left parties must shift further to the left in order to fight off right-wing populists such as Trump and France's Marine Le Pen. Supporters of these leaders, they argue, are motivated by a sense of economic insecurity in an increasingly unequal world; promise them a stronger welfare state, one better equipped to address their fundamental needs, and they will flock to the left.

"[It's] a kind of liberal myth," Pippa Norris, a Harvard political scientist who studies populism in the United States and Europe, says of the Sanders analysis. "[Liberals] want to have a reason why people are supporting populist parties when their values are so clearly against progressive values in terms of misogyny, sexism, racism."

The problem is that a lot of data suggests that countries with more robust welfare states tend to have stronger far-right movements. Providing white voters with higher levels of economic security does not tamp down their anxieties about race and immigration - or, more precisely, it doesn't do it powerfully enough. For some, it frees them to worry less about what it's in their wallet and more about who may be moving into their neighborhoods or competing with them for jobs.

Take Britain's Labour Party, which swung to the populist left by electing Jeremy Corbyn, a socialist who has proposed renationalizing Britain's rail system, as its leader in 2015. The results have been disastrous: the Brexit vote in favor of leaving the European Union, plummeting poll numbers for both Corbyn and his party, and a British political scene that is shifting notably to the right on issues of immigration and multiculturalism....

anne -> Dan Kervick... , March 14, 2017 at 07:56 AM
https://www.weforum.org/agenda/2017/01/full-text-of-xi-jinping-keynote-at-the-world-economic-forum

January 17, 2017

Speech to Davos

Wrtten by Xi Jinping
President of the People's Republic of China

I'm delighted to come to beautiful Davos. Though just a small town in the Alps, Davos is an important window for taking the pulse of the global economy. People from around the world come here to exchange ideas and insights, which broaden their vision. This makes the WEF annual meeting a cost-effective brainstorming event, which I would call "Schwab economics".

"It was the best of times, it was the worst of times." These are the words used by the English writer Charles Dickens to describe the world after the Industrial Revolution. Today, we also live in a world of contradictions. On the one hand, with growing material wealth and advances in science and technology, human civilization has developed as never before. On the other hand, frequent regional conflicts, global challenges like terrorism and refugees, as well as poverty, unemployment and widening income gap have all added to the uncertainties of the world.

Many people feel bewildered and wonder: What has gone wrong with the world? ...

EMichael -> anne... , March 14, 2017 at 08:18 AM
Amazing he had the balls to say this:

"Countries, big or small, strong or weak, rich or poor, are all equal members of the international community. As such, they are entitled to participate in decision-making, enjoy rights and fulfill obligations on an equal basis."

Seriously?

pgl -> Dan Kervick... , March 14, 2017 at 08:11 AM
Well said. It should be about governance - not who wins a popularity contest.
Dan Kervick -> anne... , March 14, 2017 at 06:55 AM
I agree with Beauchamp that what we are seeing in the US and Europe is a broader wave against liberalism itself, not just a vote for some particular economic policy or other. But for writers like Beauchamp, it always seems to be just a coincidence that this great antiliberal wave coincides with the aftermath of the worst economic catastrophe since the Great Depression. Doesn't he wonder what causes upticks in xenophobia and racism, resistance to immigration, and similar behaviors? These things rise when people are unhappy about many other things in their lives. And that happens when a country is not thriving economically.

I suspect one source of western malaise is exasperation with liberalism - whether of the rightish, laissez faire capitalist variety or of leftish neoliberal capitalism + welfare state variety – is that contemporary liberalism takes an overly passive view toward future, deferring all of the major social outcomes to the inventions and innovations or capitalist entrepreneurs, and neglecting any strategic planning role for government.

In my lifetime, China as transformed itself from a land of impoverished peasants into a world economic powerhouse, doing it with a combination of capitalist and socialist mechanisms. Meanwhile, we in the US just drift along in the end-of-history shallows, waiting to see what new toy clever business-people will invent for us. We're destroying the planet and its biosphere, & yet the usual neoliberal response is "Maybe Gates or Musk will think of something."

"Tacking to the left" economically must be understood as more than expansion of the welfare state. It includes expansion of the government role in planning and setting the agenda or direction in the productive sphere, and also regulating firms and the distribution system at the root level, to assure a more equitable distribution of income. People must be guaranteed the possibility of stable and secure lifetime employment, and reliable retirement incomes, and protected from the economic devastation of personal healthcare emergencies. Meanwhile, we need to use government to formulate and execute long term economic plans.

People are bored and dismayed by the lack of purpose, leadership, direction and transformative ambition from our dysfunctional and complacent governments. They respond to "Make America Great Again" message because at least they detect some sense of energy and purpose behind that message. So yes, I sort of agree with Beauchamp to this extent: people are turning against liberalism itself, which seems decrepit, vacuously individualistic and adrift. So, the question is how to save what is good in liberalism, while moving on and forward from what is shallow & decadent in it. Do you want fascism? Or a reinvigorated, purposeful & powerful left with an ambitious plan for engineering a viable future?

JF -> Dan Kervick... , March 14, 2017 at 07:42 AM
Enjoy the writing and thought. Thanks.

The lessons to be taken from China, as you note above, is that they have reached the conclusion that things like pricing mechanisms and markets and even the enforceability of loan contracts, if desired, all work well to effect a societally useful economic system. This is what needs to be higlighted when trying to reach westerm thinkers, in my opinion.

The central and authoritarian control aspects are not good points to highlight - in China, in Russia, or in the US. These aspects offend me and many.

JF -> JF... , March 14, 2017 at 07:47 AM
But we do need thoughtful and intentional economic policies uniformly established via the public's law, if we can keep the Republican-form aspects that legitimize US governance; and we are losing this 'we the people' aspect to a radical faction who would implement their notion of central plans of benefit to their new aristocracy.
Dan Kervick -> JF... , March 14, 2017 at 01:03 PM
China didn't get decades of gigantic growth rates just by handing its economy over to markets and private contracts. They have had a national investment plan and long-term strategy spearheaded by a heavily-involved and assertive central government.

Yes I know many Americans are offended by the very idea of central planning, and have powerful, kneejerk reactions to all suggestions of that kind. Well, they can keep being offended and we keep drifting along with our old-fashioned ideas of radically decentralized liberal capitalism. We can keep letting our wonderful capitalist freedom cook the planet and decimate the biopshere, and segregate our anxious, increasingly angry population into winners and losers at each others's throats.

RC AKA Darryl, Ron -> Dan Kervick... , March 14, 2017 at 07:47 AM
Well said.

[Mar 16, 2017] Pence HIP aka Healthy Indiana Plan which means Medicaid expansions in IN is under threat from Trump administration of which Pense is a part

Mar 16, 2017 | economistsview.typepad.com
pgl : March 14, 2017 at 01:49 AM , 2017 at 01:49 AM
Here is a link to the CBO report:

https://www.cbo.gov/sites/default/files/115th-congress-2017-2018/costestimate/americanhealthcareact_0.pdf

Tom Price says it is not believable. I guess he does not want to admit that 24 million people will lose their insurance but I bet his colleagues will hype this:

"CBO and JCT estimate that enacting the legislation would reduce federal deficits by $337 billion over the 2017-2026 period."

That's only $34 billion per year and read on:

"The largest savings would come from reductions in outlays for Medicaid and from the elimination of the Affordable Care Act's (ACA's) subsidies for nongroup health insurance. The largest costs would come from repealing many of the changes the ACA made to the Internal Revenue Code-including an increase in the Hospital Insurance payroll tax rate for high-income taxpayers, a surtax on those taxpayers' net investment income, and annual fees imposed on health insurers-and from the establishment of a new tax credit for health insurance."

Hey it is easy to reduce the deficit if one abdicates responsibility for taking care of the truly needy. But hey – more tax cuts for the rich!

jonny bakho -> pgl... , March 14, 2017 at 06:11 AM
The reaction from Pence home state of Indiana:

"It's reality hitting home," Republican Senate leader Dave Long, of Fort Wayne, said earlier this month. "The issue of the working poor is real. It's not going to be easy."

More than 400,000 poor people in Indiana have health insurance after former Gov. Mike Pence, now the vice president, championed an expansion of Medicaid, which relies on the federal government for at least 90 percent of its funding.

Pence, who is being counted on by Trump to help sell the House plan, is now poised to help unwind one of his legacy achievements as governor if the bill is signed into law.

A Pence spokesman declined to comment.

Holcomb said he understands that there is a pressing need to rein in federal spending, but he said HIP 2.0, the program Pence implemented in Indiana, is working.

"I have not seen a more successful program," Holcomb said. "I don't want to overreact but I do think that HIP 2.0 is part of that answer in how our nation can address the issue of health care."

HIP = Healthy Indiana Plan = Medicaid expansions in IN under waiver
Holcomb is new governor

JF -> jonny bakho... , March 14, 2017 at 07:20 AM
Public financing, sure its successful. Happy for people there.

I assume that the reason why the proposed bill delays the Medicaid changes is so that the States that refused to sign up before get a chance to sign up for a few years.

This means that politicians who purposely sacrificed their population's health to make some ideological bow in order to undermine the successes of the ACA would get new public financing support, allowing them to claim this new success. Unctuous. Ugly.

I wonder how CBO scored this, did they recognize that new States would sign on to the Medicaid increased Fed Financing Supports for a few years, increasing the benchmark numbers for the block grants that then replace Medicaid in those States.

Again, I would be more than sanguine to see these States poorer populations better served, that would be success, at least for a few years. But the politics are radical, bald and unseemly.

And annual fiscal changes would be less then too, and wonder what CBO considered would happen.

JF -> JF... , March 14, 2017 at 09:19 AM
CBO gave no details but nited that State reactions to the bills provisions are uncertain.

If we presume all those nonparticipating states actually sign on to the ACA until the medicaid elements are changed in 2020, at which time they would do something to protect their budgets, the national budget savings would shrink. These are areas worth congressional hearing questions of CBO.

Apparently the bill proposes to grant special subsidies to the state who had not joined before. This rewards those zealots for screwing their own people, it is sad, but It is better to expand than screw them some more. Such bald, raw political engineering here.

Again, deserves congressional questions of CBO to explain their assumptions and to highlight this reward for what it is.

[Mar 14, 2017] Turns out, some kinds of health insurance plans provide better customer service than others. Among those that do are plans offered directly by hospitals or health systems

Mar 14, 2017 | economistsview.typepad.com

Fred C. Dobbs : March 13, 2017 at 07:23 AM

Lousy Customer Service? A Better Way in Health Care
https://nyti.ms/2mBJxmw via @UpshotNYT
NYT - Austin Frakt - MARCH 13, 2017

You've all experienced it: There's a problem with your health care bill, or you have difficulty getting coverage for the care you need. Your doctor or hospital tells you to talk to your insurer. Your insurer tells you to talk to your doctor or hospital. You're stuck in an endless runaround.

A small patient advocacy industry has sprung up to help, but that help can cost several hundred dollars an hour. Is there a way to get the customer service we deserve?

Turns out, some kinds of health insurance plans provide better customer service than others. Among those that do are plans offered directly by hospitals or health systems, according to results from a recent study by me; Garret Johnson, now a medical student at Harvard; and Zoë Lyon, a research assistant at the Harvard T.H. Chan School of Public Health.

Our conclusions are based on analysis of Medicare Advantage plans - private insurance alternatives to traditional Medicare. Medicare Advantage plans are offered by major insurers like UnitedHealthcare, Humana, Aetna, BlueCross BlueShield affiliates and others. But nearly one-quarter of the plans are issued by hospitals or health systems. These provider-offered plans are more likely found in dense, urban areas in the Northeast and the West.

The government collects data on health care quality from surveys and medical claims, then aggregates them into ratings of plans. These are publicly reported in units of stars: Five stars represents the highest quality, and one the lowest. Our study, published this month in the health policy journal Health Affairs, found that provider-offered plans have higher quality ratings.

(Provider-Offered Medicare Advantage Plans:
Recent Growth And Care Quality
http://content.healthaffairs.org/content/36/3/539.abstract )

Plans offered by insurers have average ratings of just over 3.5 stars for both nondrug and drug service. An average provider-offered plan has quality ratings that are about one-third of a star higher for both, after adjusting for factors that could confound the comparison, like socioeconomic status and the types and number of doctors where plans are offered.

Our study dug deeper to examine the kinds of quality enhancements available in provider-offered plans. Some aspects of quality are clinically focused. For instance, measures of preventive screening - like that for colorectal cancer - or management of chronic conditions assess the quality of care delivered by doctors and hospitals in a plan's networks. Provider-offered plans perform somewhat better than insurer-offered plans in such areas.

Other aspects of quality pertain to customer service. In measures of complaints, responsiveness to customers and the enrollees' overall experiences, provider-offered plans really shine. In each area of customer service we examined, provider-offered plans are rated one-half star higher than insurer-offered ones. (This is a big difference. For comparison, over half of plans are within one star of each other in overall quality.)

These results make some sense. When a customer has an issue - like a problem with a hospital bill - the easiest thing for a health plan to do is pass it off to the hospital. Likewise, the hospital's easiest course of action is to blame the health plan. The patient, stuck in the middle, is not likely to rate his plan (or hospital) highly for customer service in this case.

However, when the plan and hospital are one and the same, neither can pass the buck to the other. Problems may be resolved faster; they may be less likely to develop in the first place. This could lead to the higher customer satisfaction reflected in the quality ratings.

If the higher ratings are enough to interest you in trying a provider-offered plan, how would you find one? Unfortunately, there's no readily accessible source to inform consumers (or researchers) about this feature of plans. Sometimes the plan's name gives away the relationship. The UPMC Health Plan practically has the health system that offers it right in the name - UPMC stands for University of Pittsburgh Medical Center. In other cases, consumers can identify the relationship on plans' or health systems' websites. For example, the Vital Traditions plan website identifies as its parent company the largest nonprofit hospital system in Texas, Baylor Scott & White.

But in many cases, it's not so easy to figure out. In fact, this is why there has been so little analysis of provider versus insurer plans. For our study, we had to scroll through hundreds of websites, news articles and documents to build a research data set on provider-offered plans from 2011 to 2015. Because of the work involved, there are very few studies on the subject. Another, published in Health Service Research by me, Roger Feldman of the University of Minnesota and Steven Pizer of Northeastern University, found a similar quality relationship when examining 2009 data.

That earlier study also found that provider-offered Medicare Advantage plans charge higher premiums. But a recent study of marketplace plans found that provider-offered ones are not necessarily the most expensive. For some, a higher premium may outweigh the benefits of greater quality, but for others it may not.

From our study, we can't be certain that provider sponsorship of plans causes higher quality. It could be that higher-quality providers are the ones that choose to offer plans. Nevertheless, such tight integration between plans and providers is at least a signal of higher quality, even if it doesn't cause it.

Recent trends suggest more health systems are offering plans in other health care markets for the working-age population, not just in Medicare Advantage. Not all markets may be hospitable to provider-offered plans, however. Some systems that did offer plans are pulling back. According to The Wall Street Journal, Catholic Health Initiatives, which runs over 100 hospitals across 18 states, is divesting itself of some of its health insurance plans. After struggles with profitability, Tenet Healthcare and several other health systems have said they will do the same. ...

Big hospital operator retreats from health-insurance foray
http://www.wsj.com/articles/big-hospital-operator-retreats-from-health-insurance-foray-1481814003
via @WSJ - December 15

[Mar 14, 2017] It was in 1989 that economist Stuart Butler proposed an individual mandate in a Heritage Foundation monograph,

Notable quotes:
"... It was in 1989 that economist Stuart Butler proposed an individual mandate in a Heritage Foundation monograph, A National Health System for America, practically on the eve of Bush's inauguration: ..."
"... The requirement to obtain basic insurance would have to be enforced. The easiest way to monitor compliance might be for households to furnish proof of insurance when they file their tax returns. If a family were to cancel its insurance, the insurer would be required to notify the government. If the family did not enroll in another plan before the first insurance coverage lapsed and did not provide evidence of financial problems, a fine might be imposed. ..."
"... In 1991 Mark Pauly, of the University of Pennsylvania, elaborated on the concept, in a widely-read article in the journal Health Affairs. The individual mandate became the basis for a Congressional Republican proposal introduced in 1993 as an alternative to Hillary Clinton's anticipated proposal of a single-payer national health service. The scheme was subsequently endorsed (subscription required) by Newt Gingrich. ..."
Mar 14, 2017 | economistsview.typepad.com
Peter K. : March 13, 2017 at 05:46 AM

Fred Dobbs corrected me by saying Romenycare started in Massachusetts, not a Republican think tank. Not according to David Warsh in today's links.

"How did a Republican program introduced on the eve of the George H.W. Bush administration wind up in the crosshairs of the Republican Congress under House Speaker Paul Ryan (R-Wis.) twenty-five years later? Here, at the beginning of the attempt to repeal Obamacare, let's take a quick trip down memory lane.

It was in 1989 that economist Stuart Butler proposed an individual mandate in a Heritage Foundation monograph, A National Health System for America, practically on the eve of Bush's inauguration:

The requirement to obtain basic insurance would have to be enforced. The easiest way to monitor compliance might be for households to furnish proof of insurance when they file their tax returns. If a family were to cancel its insurance, the insurer would be required to notify the government. If the family did not enroll in another plan before the first insurance coverage lapsed and did not provide evidence of financial problems, a fine might be imposed.

That autumn, in Assuring Affordable Health Care for All Americans, a conference talk, Butler explained why the provision of health care is unlike almost all other markets:

If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance. If we find that he has spent his money on other things rather than insurance, we may be angry but we will not deny him services – even if that means more prudent citizens may wind up paying the tab.

In 1991 Mark Pauly, of the University of Pennsylvania, elaborated on the concept, in a widely-read article in the journal Health Affairs. The individual mandate became the basis for a Congressional Republican proposal introduced in 1993 as an alternative to Hillary Clinton's anticipated proposal of a single-payer national health service. The scheme was subsequently endorsed (subscription required) by Newt Gingrich.

..."

http://www.economicprincipals.com/issues/2017.03.12/1980.html

Up above in comments, PGL is getting all strident about Paul Ryan watering down what is essentially a Republican water-downed alternative to Hillarycare.

"He is gloating that we have more "choices" as he takes away any possible means for actually paying for our health care. This in a nutshell is the entire GOP approach. We are free to die."

The comedians are having a fun time pointing out how Trump won't put his name on the replacement plan even though he loves putting his name on things.

Peter K. -> Peter K.... , March 13, 2017 at 05:51 AM
Was Hillarycare a single-payer?

https://en.wikipedia.org/wiki/Clinton_health_care_plan_of_1993

"To achieve this, the Clinton health plan required each US citizen and permanent resident alien to become enrolled in a qualified health plan on his or her own or through programs mandated to be offered by businesses with more than 5,000 full-time employees. Subsidies were to be provided to those too poor to afford coverage, including complete subsidies for those below a set income level. Users would choose plans offered by regional health alliances to be established by each state. These alliances would purchase insurance coverage for the state's residents and could set fees for doctors who charge per procedure.[5][6] The act provided funding to be sent to the states for the administration of the plan, beginning at $14 billion in 1993 and reaching $38 billion in 2003."

im1dc -> EMichael... , March 13, 2017 at 08:44 AM
Short Sweet Bernie Sanders Takedown of the Ryan Repeal and Replace Health Care Plan

http://www.politicususa.com/2017/03/12/bernie-sanders-demolishes-paul-ryans-obamacare-replacement-incredible-82-seconds.html

"Bernie Sanders Demolishes Paul Ryan's Obamacare Replacement In An Incredible 82 Seconds"

By Jason Easley...Mar 12th, 2017

"Sen. Bernie Sanders needed just 82 seconds to completely demolish Speaker of the House Paul Ryan's Obamacare replacement on Face The Nation.

The full interview with Sen. Sanders on CBS's Face The Nation:

Face The Nation video

Sen. Sanders was asked if the Ryan Obamacare replacement can get 51 votes in the Senate, and he answered, "I hope not. It is an absolute disaster. It is a disgrace, and by the way, this really has nothing to do with healthcare. What this has everything to do with is a massive shift of wealth from working people and middle-income people to the richest people in this country. It is a 275 billion dollar tax break for the top two percent. Millionaires will get about $50,000 a year in tax breaks, while at the same time 5-10 million people are going to lose their health insurance, premiums are going to soar. The AARP says that if you are 64 years of age and you're making about 25,000 a year, you're going pay up to $7,000 more for you're health insurance. They're going to defund Planned Parenthood. Deny over 2 million the right to choose they healthcare that they need. They're going to decimate Medicaid, which is why the American Medical Association, the AMA, and the American Hospital Association oppose it, in addition to the AARP. This is a disgrace, and by the way, they are so cowardly that they want to go forward before the CBO gives an estimate of what it will cost, and how many people will lose their insurance."...

im1dc : , March 13, 2017 at 09:30 AM
Anyone mention Single Payer? No? Why not...

"Republican lawmakers think the biggest problem with health insurance is that too many people have it"

http://www.marketwatch.com/story/ryancare-doesnt-fix-health-care-but-here-are-some-ideas-that-would-2017-03-10

"Ryancare doesn't fix health care, but here are some ideas that would"

By Rex Nutting, Columnist...Mar 13, 2017...7:53 a.m. ET

"Congressional Republicans are moving forward with a bill to repeal and replace the Affordable Care Act, but the proposed bill doesn't do very much to improve on the flaws in Obamacare. The Republican plan doesn't solve any of our health-care problems, because it wasn't designed to.

Instead, it tries (and fails) to solve a political problem.

What are the main complaints about Obamacare? That, even with subsidies, health care is too costly, with rising premiums and high out-of-pocket costs. That, in some areas, there aren't enough choices for health insurance, and there aren't enough choices about doctors or other medical-care providers. That there's a mandate to purchase insurance, even if you're healthy.

Paul Ryan's replacement bill doesn't address any of those concerns. Instead, it would drive costs up for almost everyone except the very healthy and the very rich, and would hit those in their 50s and 60s particularly hard. It would phase out expanded Medicaid coverage, so millions of working-class Americans would lose their insurance completely. It doesn't guarantee that you'll have more choices, and it maintains a mandate to buy insurance.

Unfortunately, the bill's penalty for not buying continuous insurance coverage would create such perverse incentives that it would likely result in even fewer healthy people buying health insurance, which would in turn lead to higher premiums for sick people as the insurance pool becomes smaller and sicker, culminating in the very "death spiral" that supposedly killed Obamacare.

So what is the Republican bill all about? It's an attempt to square the circle politically. Republicans have an intractable problem: People really like having health insurance and the care that goes with it, but Republican lawmakers think the biggest problem with health insurance is that too many people have it.

As Mike Konczal writes: "Conservatives talk compassion, but they really believe that the problem with health care is too much coverage, too little risk for individuals and too much taxation."

Or as my colleague Caroline Baum writes: "Republicans are getting a crash course on what they already knew, or should have known: once an entitlement, always an entitlement." In other words, Republicans should go back to the principle that no one should get anything they can't afford. There's no free lunch, and no free health care.

As you can see, there is no way to square this. People want affordable health care, and Republicans don't want to give it to them. So of course the bill is a mess, pleasing no one except those who foolishly think that the people wouldn't notice that the Republicans had replaced Obamacare with something much worse.

The problems of health care

So how should we improve our health-care system? The first step is to identify what's wrong with it. Several things:

...Everyone should be insured, with the costs fairly divided among all of us. Make it so.

...We could control some costs by shifting the way we reimburse doctors and hospitals.

...We should make sure that health-care providers don't benefit financially from the treatments they prescribe.

...Introducing more competition would drive down prices.

...let's take away the patents for drugs and medical equipment and establish alternative means of encouraging research, innovation and invention

...Finally, we need more transparency about prices, as well as about the risks and benefits of the treatments recommended for us. Prices ought to be posted on the wall of every waiting room and admittance office."...

[Mar 14, 2017] No wonder the unemployed increasingly kill themselves, or others. The whole economy tells them, indirectly but unmistakably, that their human value does not exist.

Mar 14, 2017 | economistsview.typepad.com
Noni Mausa : March 13, 2017 at 04:13 PM

What the wealthy right wing has decided in the past 40 years is that they don't need citizens. At least, not as many citizens as are actually citizens. What they are comfortable with is a large population of free range people, like the longhorn cattle of the old west, who care for themselves as best they can, and are convenient to be used when the "ranchers" want them.

Of course, this is their approach to foreign workers, also, but for the purpose of maintaining a domestic society within which the domestic rich can comfortably live, only native born Americans really suit.

With the development of high productivity production, farming, and hands-off war technology the need for a large number of citizens is reduced. The wealthy can sit in their towers and arrange the world as suits them, and use the rest of the world as a "farm team" to supply skills and labour as needed.

Proof of this is the fact that they talk about the economy's need for certain skills, training, services and so on, but never about the inherent value of citizens independent of their utility to someone else.

No wonder the unemployed increasingly kill themselves, or others. The whole economy tells them, indirectly but unmistakably, that their human value does not exist. ken melvin : , March 13, 2017 at 04:48 PM

Can someone get me from $300 billion tax cut for the rich to getting the markets work for health care?
ken melvin : , March 13, 2017 at 04:54 PM
It isn't about 'markets', never is. It is about extraction of as much profit as possible using whatever means necessary. This is what the CEOs of insurance companies get payed to do. Insurance policies they don't pay out, the ones Ryan is referring to, are as good as any for scoring.
libezkova : , March 13, 2017 at 07:09 PM
"It isn't about 'markets', never is. It is about extraction of as much profit as possible using whatever means necessary. This is what the CEOs of insurance companies get payed to do."

What surprises me most in this discussion is how Obamacare suddenly changed from a dismal and expensive failure enriching private insurers to a "good deal".

Lesseevilism in action ;-)

ilsm : , March 13, 2017 at 01:41 PM
When the PPACA band-aid is pulled off the US health care mess the gusher will be blamed on "the Russians running the White House".

Cuba does better than the US despite being economically sanctioned for 55 years. Distribution of artificially scarce health care resources is utterly broken. This failed market is financed by a mix of 'for profit' insurance and medicare (which sublets a big part to 'for profit' insurance).

Coverage!!! PPACA added taxpayers' money to finance a bigger failed market. It did nothing to address the market fail!

Single payer would not address the market failure. Single payer would put the government financing most of the failed market.

Democrats have put band-aids on severe bleeds since Truman made the cold war more important than Americans.

At least we know what Trump stands for!

jeff fisher said in reply to ilsm... , March 13, 2017 at 01:58 PM
Cuba is the shining example of how doing the first 20% of healthcare well for everyone gets you 80% of the benefit cheap.

The US is the shining example of how refusing to do the first 20% of healthcare well for everyone only gets you 80% of the benefit no matter how much you spend.

jonny bakho : , March 13, 2017 at 12:09 PM
Mark's very nice argument does nothing to address The Official Trump Counter Argument:

[Shorter version: Obamacare is doomed, going to blow up. Any replacement is therefore better than Obamacare; Facts seldom win arguments against beliefs]

"During a listening session on healthcare at the White House on Monday, President Donald Trump said Republicans "are putting themselves in a very bad position by repealing Obamacare."

Trump said that his administration is "committed to repealing and replacing" Obamacare and that the House Obamacare replacement will lead to more choice at a lower cost. He further stated, "[T]he press is making Obamacare look so good all, of a sudden. I'm watching the news. It looks so good. They're showing these reports about this one gets so much, and this one gets so much. First of all, it covers very few people, and it's imploding. And '17 will be the worst year. And I said it once; I'll say it again: because Obama's gone."

He continued, "And the Republicans, frankly, are putting themselves in a very bad position - I tell this to Tom Price all the time - by repealing Obamacare. Because people aren't gonna see the truly devastating effects of Obamacare. They're not gonna see the devastation. In '17 and '18 and '19, it'll be gone by then. It'll - whether we do it or not, it'll be imploded off the map."

He added, "So, the press is making it look so wonderful, so that if we end it, everyone's going to say, 'Oh, remember how great Obamacare used to be? Remember how wonderful it used to be? It was so great.' It's a little bit like President Obama. When he left, people liked him. When he was here, people didn't like him so much. That's the way life goes. That's human nature."

Trump further stated that while letting Obamacare collapse on its own was the best thing to do politically, it wasn't the right thing to do for the country.

http://www.breitbart.com/video/2017/03/13/trump-republicans-putting-bad-position-repealing-obamacare/

[Mar 10, 2017] Get private insurers out of the game, they are taking 20 percent of everyone's money, for no value-added

Mar 10, 2017 | economistsview.typepad.com
Lee A. Arnold -> jonny bakho... March 10, 2017 at 03:59 AM Obama and the Dems can avert the blame by saying,

"Get private insurers out of the game, they are taking 20% of everyone's money, for no value-added. Create a public option that will knock the price down, and will lead us to a single payer, like 'Medicare for All'. Healthcare can't work as a totally free market, it has to work like Medicare. Don't blame the Democrats, blame the Republicans for obstructing smart economics. ACA tried to bring everybody into the system, to reveal our true costs as a nation."

This shouldn't be hard, people!! jonny bakho -> Lee A. Arnold ... , March 10, 2017 at 04:37 AM

People do NOT like dealing with insurance period. A program that is automatic enroll / file to opt out would require less effort and be more appealing. Programs that force people to do things (Read health care legalese) will create a lot more grumbling than programs that auto enroll. It should be as simple as signing up for Medicare. The GOP could buy good will by keeping most of ObamaCare and changing the process. However, the primary GOP goal is to eliminate the taxes on the wealthy that pay for Obamacare subsidies. It is not to do something for their uninsured voters
Lee A. Arnold -> jonny bakho... , March 10, 2017 at 04:51 AM
Totally agree in regards to healthcare, (and we should get rid of the Medicare donut-hole too). Note that part of Obamacare's taxation covers the shortfall in Medicare, so that repealing Obamacare puts Medicare back into jeopardy. Probably one reason that the GOP is trying to avoid a CBO score for as long as possible. Medicare goes on the chopping-block next, make no mistake about it.
Lee A. Arnold -> Lee A. Arnold ... , March 10, 2017 at 05:07 AM
If you have watched a senior try to deal with the Medicare donut-hole, you realize the enormous and cruel burden it places upon some of them. A county-level bureaucrat advised me that this travesty was included to make some people get sick and die faster, so that they don't burden the Medicare system. Old people can get the idea that they have no right to live, because the money ain't there; they don't want to be a burden.
Benedict Arnold -> Lee A. Arnold ... , -1

county-level bureaucrat advised me that this travesty was included to make some people get sick and die faster, so that they
"
~~Lee A. Arnold said~

This is even worse!

"
Senator Michael Enzi and Michigan Representative Fred Upton advocated the extension from October into November especially to allow children to go trick-or-treating in more daylight.[13]

Under Section 110 of the Act, the U.S. Department of Energy was required to study the impact of the 2007 DST extension no later than nine months after the change took effect. The report, released in October 2008, reported a nationwide electricity savings of 0.03% for the year of 2007.[14]

An October 2008 study conducted by the University of California at Santa Barbara for the National Bureau of Economic Research found that the 2006 DST adoption in Indiana increased energy consumption in Indiana by an average of 1%. Although energy consumption for lighting dropped as a result of the DST adoption, consumption for heating and cooling increased by 2 to 4%.
"

From this can you easily visualize what a bunch of clowns and jokers we have in Congress? Look!

Railroads, ships, and planes need a consistent system of time that is the same in all parts of the World, the kind of time that does not confuse the human mind. Sure!

computers can be properly reprogrammed to compensate for the stupidity of Congress, but humans using the computers and programming the computers have been confused enough already. We need to revert back to Greenwich Mean Time that has been slightly tweaked by atomic clock but essentially the same in all countries simultaneously. Look!

There is nothing wrong with having lunch at 7:00 in Washington; nothing wrong with having midnight at 19:00 in DC. Hell!

That's even better! At least you know where you are on the planet just from knowing when folks have sun-transit. Sure!

Folks can move trick-or-treat to a different schedule or move school-bus to a different time whenever they like. Sure! Folks can change from one month to the next when to open the glof-course, but don't try to change the entire system of conventional time just to suit your golfing foursome!

Fore
!

pgl -> Lee A. Arnold ... , March 10, 2017 at 05:43 AM
"they are taking 20% of everyone's money, for no value-added. Create a public option that will knock the price down". Exactly.

Their gross margin have risen above 20%. We are talking about operating expenses near 15% of premium revenue which is about twice what this should be. Profits margins are near 6% of premium revenue which translates into ROAs near 25%. And reasonable analysis would suggest that the cost of capital is less than 8% so profit margins closer to 2% would be generous.

Of course - we know why. An oligopoly structure means no real competition. But that is what Paul Ryan wants as he is bought and paid for by the health insurance oligopolists. Remember that when they talk about "free market principles". All talk - no reality.

Lee A. Arnold -> pgl... , March 10, 2017 at 05:55 AM
I thought that ACA restricted the insurers to a "medical loss ratio" (MLR) no lower than 80%, i.e. no more than 20% for themselves.
Anachronism -> Lee A. Arnold ... , March 10, 2017 at 06:00 AM
It does. Don't know about anyone else in this blog, but I'm self employed and buy my own insurance, so I am directly affected by ACA.

Every August, I get a check from Blue Cross for the excess charged (that "no more than 20% for themselves). This year is was just a hair under $2K.

pgl -> Anachronism ... , March 10, 2017 at 06:36 AM
This gives me a thought about the usual Republican babble as to how price controls create shortages (their free market spin of late). Let's suppose my back of the envelope guess of what a competitive gross margin should be is right - that it would be 10% but for the oligopoly structure. With the oligopoly and no ceiling - let's say they are getting a 25% gross margin off of us not on ACA. Then the ACA ceiling is actually a movement towards competition both lowering prices and increasing quantity provided. Standard economics for a market infested with monopoly power.

This says there are two ways to move the market more efficient - either enforce competition (public option) or impose a lower ceiling. So ACA did not go far enough with this 20% ceiling. It should be cut in half.

Anachronism -> pgl... , March 10, 2017 at 06:57 AM
Maybe non-serious republicans think the health insurance market is a free-market situation, but I don't see how. It is rife with imperfect knowledge about the marketplace and failures in pricing.

Without knowing if your back-of-the-envelope is correct, I'd guess the difference between the 10% margin and the actual 20% is a political quid pro quo (I give you the extra 10% and you support the legislation).

What I can say is that I know Medicare operates with a 3 1/2% overhead margin, so moving to a public option should definitely reduce premiums.

pgl -> Lee A. Arnold ... , March 10, 2017 at 06:20 AM
You may be right but ACA covers only a subset of the population. I'm thinking about the overall financials for these companies. Maybe this is why they don't like ACA. They prefer setting this absurdly high gross margin even higher. It could be and should be less than 10%.
EMichael -> pgl... , March 10, 2017 at 06:52 AM
The ACA mandates a MLR of 85% for employer provided insurance.
anne -> Lee A. Arnold ... , March 10, 2017 at 07:32 AM
"Get private insurers out of the game, they are taking 20% of everyone's money, for no value-added...."

Where is this quote taken from? I assume the 20% figure refers to the Medical Loss ratio, * but I do not understand how low that ratio could be under any insurance system.

* https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Medical-Loss-Ratio.html

The Affordable Care Act requires health insurance issuers to submit data on the proportion of premium revenues spent on clinical services and quality improvement, also known as the Medical Loss Ratio (MLR). It also requires them to issue rebates to enrollees if this percentage does not meet minimum standards. The Affordable Care Act requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the rate review provisions imposing tighter limits on health insurance rate increases.

Lee A. Arnold -> anne... , March 10, 2017 at 08:31 AM
Anne: "I do not understand how low that ratio could be under any insurance system"

I think that Social Security and Medicare only spend around 2%.

anne -> Lee A. Arnold ... , March 10, 2017 at 08:39 AM
"I do not understand how low that Medical Loss ratio could be under any insurance system"

I think that Social Security and Medicare only spend around 2%.

[ This is what I was after and is especially important. What we need then is to document the administrative cost of Medicare and Social Security. ]

EMichael -> Lee A. Arnold ... , March 10, 2017 at 08:48 AM
A little higher than that, but obviously lower. At the same time, SS does not count except that it makes Medicare Admin costs lower.

Also, admin costs will be lower when you are talking about the simple fact that once people are on Medicare there are no changes(or not many) that has to be dealt with. In the private marketplace there are constant changes(births, policy changes, etc), and these make for higher admin costs.

Not to say these costs are not too high, but there will be higher admin costs for those under 65.

Lee A. Arnold -> EMichael... , March 10, 2017 at 09:40 AM
EMichael: "there will be higher admin costs for those under 65."

Put everybody into one big public risk pool, & the incidence of disease, the treatment costs, and the actuarial tables ought to be pretty steady and predictable.

EMichael -> Lee A. Arnold ... , March 10, 2017 at 09:46 AM
Of course they would. I said the same thing.

Just saying they will not be as low as Medicare, and that the insurance companies do not increase costs by 20%.

Lee A. Arnold -> EMichael... , March 10, 2017 at 10:25 AM
I am not sure I understand you. In a universal public healthcare system, why would administrative costs be different than for Medicare?
anne -> Lee A. Arnold ... , March 10, 2017 at 08:49 AM
http://www.pnhp.org/sites/default/files/Medicare_admin_costs_JHPPL.pdf

February 15, 2013

How to Think Clearly about Medicare Administrative Costs: Data Sources and Measurement
By Kip Sullivan

Abstract

The Centers for Medicare and Medicaid Services (CMS) annually publishes two measures of Medicare's administrative expenditures. One of these appears in the reports of the Medicare Boards of Trustees and the other in the National Health Expenditure Accounts (NHEA). The latest trustees' report indicates Medicare's administrative expenditures are 1 percent of total Medicare spending, while the latest NHEA indicates the figure is 6 percent. The debate about Medicare's administrative expenditures, which emerged several years ago, reflects widespread confusion about these data. Critics of Medicare argue that the official reports on Medicare's overhead ignore or hide numerous types of administrative spending, such as the cost of collecting taxes and Part B premiums. Defenders of Medicare claim the official statistics are accurate. But participants on both sides of this debate fail to cite the official documents and do not analyze CMS's methodology. This article examines controversy over the methodology CMS uses to calculate the trustees' and NHEA's measures and the sources of confusion and ignorance about them. It concludes with a discussion of how the two measures should be used.

anne -> anne... , March 10, 2017 at 09:03 AM
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

December 6, 2016

Historical

The National Health Expenditure Accounts (NHEA) are the official estimates of total health care spending in the United States. Dating back to 1960, the NHEA measures annual U.S. expenditures for health care goods and services, public health activities, government administration, the net cost of health insurance, and investment related to health care. The data are presented by type of service, sources of funding, and type of sponsor.

anne -> anne... , March 10, 2017 at 09:09 AM
http://www.pnhp.org/sites/default/files/Medicare_admin_costs_JHPPL.pdf

February 15, 2013

Medicare Administrative Expenses as Percent of Total Expenditures

( Medicare Trustees) ( National Health Expenditure Accounts)

2000 ( 2.0) ( 3.8)
2001 ( 1.6) ( 3.5) Bush
2002 ( 1.8) ( 3.3)
2003 ( 1.7) ( 3.1)
2004 ( 1.9) ( 3.6)

2005 ( 1.8) ( 4.0)
2006 ( 1.5) ( 5.3)
2007 ( 1.5) ( 5.6)
2008 ( 1.4) ( 5.3)
2009 ( 1.3) ( 5.7) Obama

2010 ( 1.3) ( 5.9)
2011 ( 1.4)

-- Kip Sullivan

Lee A. Arnold -> anne... , March 10, 2017 at 09:45 AM
Considering the jump in administrative expenses in the National Health Expenditure Accounts after 2004, we ought to investigate whether this was caused by the passage of privatized Medicare Part D in 2003.
pgl -> anne... , March 10, 2017 at 09:34 AM
Even at 6%, this is far lower than what the private insurers pay.
pgl -> anne... , March 10, 2017 at 09:32 AM
Aetna's 10K reports its health care costs relative to its health care premiums. That is the main part of its gross profit margin and indeed it is as high as he says. And I still stand by my contention that this margin could be cut in half.
anne -> pgl... , March 10, 2017 at 09:49 AM
Supposing I understand the research, administration costs for Medicare ranged between 1.3% and 5.9% of total Medicare spending between 2000 and 2010. Medical Loss ratios for insurers under the Affordable Care Act have been set between 80% and 85%. Here then we would seem to have boundaries within which to argue.
New Deal democrat -> jonny bakho... , March 10, 2017 at 04:49 AM
Yes, agreed. Just to flesh out your point a little ...

The GOP really wants to repeal Obamacare in full and "replace" it with "save money for when you get sick." Oh, and tax cuts for the rich as always.

But they can't do that outright now that 20 million people have coverage under Obamacare, and it is really helping them.

So in "phase 1" of their plan, they kick away the funding, for which they only need 50 votes (+the VP) in the Senate.

"Phase 2" deals with the coverage. It is really crappy. They can accomplish this by nuking the filibuster, *OR* they can tell Dems that if they don't go along, they will get blamed for the death spiral of the existing law (now that funding is gone). Since the GOP plan is also designed to go into a death spiral, the Dems probably will hold the line.

But either way, there is a death spiral. The GOP wurlitzer will be easier to crank up with blaming the Dems when they don't go along. And since it will block grant Medicaid and cause the Medicare trust fund to be exhausted in 2024, it tees up the next round of gutting the civil state.

reason -> New Deal democrat... , March 10, 2017 at 05:12 AM
This is the Republican plan - but it is a disaster for Trump. The problem is of course that he is too stupid to realize it.
reason -> jonny bakho... , March 10, 2017 at 05:09 AM
placate (not place) - for those who are having trouble reading jonny bakho here.

[Mar 10, 2017] All roads politically lead to a single-payer (perhaps accompanied by a secondary market for add-on coverage for the rhinestone-encrusted lifestyle) however long and bumpy the road will be.

Mar 10, 2017 | economistsview.typepad.com
jonny bakho : March 10, 2017 at 04:30 AM

, 2017 at 04:30 AM
Kevin Drum understands:
Republicans knew exactly what problem they were trying to solve. Their preference has always been to repeal Obamacare and do nothing in its place, but they don't have the votes to overcome a Democratic filibuster, so they can't do that. They also realize that the optics of baldly ripping away health coverage from 20 million people would be mildly troublesome.

So their goal was simple: do what they could to destroy Obamacare and take away as much health coverage as they could, without making it look like they weren't offering a replacement. The result is a plan that offers the trappings of health care-subsidies, pre-existing conditions, etc.-but which is all but useless to the people who actually need it. It's too stingy for poor people, and mostly unnecessary for middle-class folks who already get health insurance from their employers. It will cost very little because virtually nobody will use it.

The part they apparently didn't realize is that keeping the pre-existing conditions clause-which is both popular and impossible to repeal-while tearing down the rest of Obamacare is likely to destroy the individual insurance market. At least, I assume they didn't realize that, since this would be bad news even by Republican standards. Maybe they're just counting on their repeal bill failing in the Senate, so nothing bad will happen and they can get back to complaining about Obamacare.

http://www.motherjones.com/kevin-drum/2017/03/republican-health-care-bill-carefully-crafted-solve-specific-problem

Lee A. Arnold : , March 10, 2017 at 04:46 AM
It's odd that the GOP didn't understand this, because they have had enough time to figure it out. All roads politically lead to a single-payer (perhaps accompanied by a secondary market for add-on coverage for the rhinestone-encrusted lifestyle) however long and bumpy the road will be. So either they are 1. intellectually incompetent (always a good bet) or 2. they are short-term punters who understand the limited attention-span of the U.S. voter, or 3. they believe that free-market capitalism is a religious emotion that salves all wounds if only it can be impressed far enough into the psyche.
pgl -> Lee A. Arnold ... , March 10, 2017 at 05:45 AM
"they have had enough time to figure it out".

The latest GOP spin is that they have been talking about their plan for over 7 years. Really? Is that why they kept their plan a secret until a few days ago?

kthomas -> pgl... , March 10, 2017 at 08:23 AM
There was never any plan. Ryan is a charlatan.
pgl -> kthomas... , March 10, 2017 at 09:34 AM
Yep.
George H. Blackford : , March 10, 2017 at 05:38 AM
Democrats ran away from Obamacare in 2010, 2012, and 2014. Then Hillary wasted her time ridiculing Trump without offering a solution to the rising cost of healthcare except more of the same.

The obvious solution for rising healthcare costs is either a public option or extending Medicare to younger and younger people, but Democrats, other than Sanders, refuse to offer or defend these solutions.

Democrats make no more sense in this regard than the Republicans do. Why should anyone listen to Democrats in this situation when the Democrats have nothing to offer but more of the same?

pgl -> George H. Blackford ... , March 10, 2017 at 05:48 AM
Back in 1993 Mrs. Clinton was supposed to come up with some awesome health care reform. Maybe her team did but they never really got the message out clearly. In the meantime the Republicans savaged the air waves and nothing got done. ACA may have been Romney's plan but at least Obama got it past. And of course even Mitt Romney has spent the last 7 years attacking this former Republican plan. The new plan is really awful but the current Republicans are pushing it through as if it were written by God.
George H. Blackford -> pgl... , March 10, 2017 at 05:51 AM
QED
Anachronism said in reply to pgl... , March 10, 2017 at 06:03 AM
They're pushing it thru because they want it passed before the CBO can score it. They're afraid of the results.

The Brookings Institute scored it and estimated 7 million reduced from direct purchasing of healthcare, another 7 million off of Medicaid roles, and costs roughly $800 billion over 10 years.

pgl -> Anachronism ... , March 10, 2017 at 06:22 AM
I was hoping some independent and credible group would score this awful thing. I bet Paul Ryan decries Brookings as "librul".
Anachronism said in reply to pgl... , March 10, 2017 at 06:59 AM
Anyone who disagrees with them is not credible.
pgl -> Anachronism ... , March 10, 2017 at 09:35 AM
We have a consensus. As kthomas wrote:

"Ryan is a charlatan."

Ed Brown -> pgl... , March 10, 2017 at 07:54 AM
Thinking back to Mrs. Clinton's activities in 1993 on this issue: imagine if Melania Trump was currently working to architect something significant, such as trade policy. It would be odd, no? She was not elected.

The Clinton's have consistently exhibited a certain level of arrogance and entitlement which has not been helpful to the political left over the years.

Oh well, spilled milk I guess.

EMichael -> Ed Brown... , March 10, 2017 at 08:06 AM
Liberals are the worst team mates in the world.

Yeah, having HRC work on healthcare was surely an example of "arrogance and entitlement".

geez

https://learnodo-newtonic.com/eleanor-roosevelt-accomplishments

Pinkybum -> Ed Brown... , March 10, 2017 at 08:39 AM
"imagine if Melania Trump was currently working to architect something significant, such as trade policy. It would be odd, no? She was not elected."

Hahahaha! Plenty of people who are not elected work on policy.

EMichael -> Pinkybum... , March 10, 2017 at 09:09 AM
Nelson was the only Dem Senator that held his vote to end debate in order to get something. He was "paid off" and dropped his filibuster.

Lieberman, along with every Rep senator, stopped the public option.

Best part of the whole sorry process was the work of Pelosi, who took away Nelson's kickback through reconciliation. Something she could not do to Lieberman.

sanjait -> Pinkybum... , March 10, 2017 at 10:08 AM
"Hahahaha! Plenty of people who are not elected work on policy."

Yes. It was such a strange criticism.

The worst thing about Hillary Clinton is that somehow she is a magnet for this kind of faux serious critic.

It's especially odd considering that we are talking about an effort to expand healthcare access, and doubly especially odd considering the instrumental role HC played in getting SCHIP passed after "Hillarycare" crashed.

yuan -> Ed Brown... , March 10, 2017 at 09:19 AM
hopefully more like the dustbin of history...
pgl -> Ed Brown... , March 10, 2017 at 09:36 AM
Melania Trump may not be the sharpest pencil in the box but I bet she could do a better job than Peter Navarro.
jonny bakho said in reply to George H. Blackford ... , March 10, 2017 at 06:41 AM
"Hillary wasted her time ridiculing Trump without offering a solution to the rising cost of healthcare except more of the same."

This strikes me as revisionist history. The AntiObamacare voters were not persuadable. They believed and still believe Trump's lies about creating a better program.

Obamacare has been bending health care costs.

The solution to Health care costs requires reform of the medical care delivery system. There is zero public support for that

George H. Blackford -> jonny bakho... , March 10, 2017 at 08:15 AM
There is zero public support for that because Democrats, except for Sanders, refuse to make it an issue in a campaign and explain it to the American people. It was Democrats who rejected Sanders and nominated more of the same Hillary.
yuan -> George H. Blackford ... , March 10, 2017 at 09:24 AM
"There is zero public support for that because Democrats, except for Sanders"

this is not accurate, imo. a more accurate statement would be that triangulation of the democratic party (clinton and obama) into conservative territory has created a repubicanesque punish-the-poors voting block.

EMichael -> George H. Blackford ... , March 10, 2017 at 06:57 AM
I'll ignore the straw man you place firmly in your first sentence and just ask how you can say,

"Democrats make no more sense in this regard than the Republicans do."

What it means is that you think the ACA is as good as this GOP plan.

Seriously?

I am also more than a little tired of supposed liberals repeating constantly the "dems did not want the public option" meme. Beyond tiring, and self defeating.

Liberals make the worst team mates in the world.

Peter K. -> EMichael... , March 10, 2017 at 07:01 AM
They didn't want it. Obama didn't fight for it. Lieberman blocked it.

You can always count on EMichael to defend the Democrats no matter what the accusation.

Why is that?

Whose payroll is he on?

sanjait -> Peter K.... , March 10, 2017 at 10:09 AM
Peter unwittingly illustrates EMichael's point...
George H. Blackford -> EMichael... , March 10, 2017 at 08:32 AM
EMichael, What it means is exactly what I said:

The obvious solution for rising healthcare costs is either a public option or extending Medicare to younger and younger people, but Democrats, other than Sanders, refuse to offer or defend these solutions.

Democrats make no more sense in this regard than the Republicans do. Why should anyone listen to Democrats in this situation when the Democrats have nothing to offer but more of the same?

The obvious answer to that rhetorical question is that there is no reason anyone should listen to Democrats given their refusal to offer a solution to the problem of the rising cost of healthcare, and the result of this is Trump.

I think it is a bit much to blame voters for the failures of the Democrats to come up with sensible programs.

EMichael -> George H. Blackford ... , March 10, 2017 at 08:42 AM
Good is not the enemy of perfect.

In the US, there are only two choices.

The Dems tried to get a public option (which would certainly result in single payer)into law. Not one single GOP senator was even in favor of allowing the public option to get to the floor. Only one Rep House member voted for the public option.

And someone you think they are the same.

Wonder why Sanders did not try to run for the Rep nomination?

George H. Blackford -> EMichael... , March 10, 2017 at 09:06 AM
You've got it exactly right, and the Democrats refused to make it a campaign issue to bring it to the electorate and fight for it.

Neither Republicans nor Democrats make any sense on this issue since neither are willing to fight for anything that makes sense.

To my mind, what that means is that trying to defend either one against the other is nonsense.

EMichael -> George H. Blackford ... , March 10, 2017 at 09:13 AM
I don't know, maybe it is me.

Seems to me that defending a program that has saved more than 100,000 American lives makes sense.

Seem to me that defending a program that has given more than 20 million Americans health insurance makes sense.

Not perfect. But then again there are only two choices.

George H. Blackford -> EMichael... , March 10, 2017 at 09:24 AM
The moral of the story is that both the Democrats and the Republicans have proved to be so incompetent that we ended up with Trump!

It seems to me that it is a serious mistake to ignore this fact and to try to blame the mess we are in on someone else.

The fault, dear Brutus, is not in our stars But in ourselves, that we are underlings.

EMichael -> George H. Blackford ... , March 10, 2017 at 09:37 AM
Please.

Don't move that goal post on me.

I do not ignore the fact that Democrats have not been successful in their admin efforts on many levels.

Some of that is incompetence. Some of that is Rep opposition. Both can be cured.

But neither can be cured by thinking they are all the same.

Bernie Sanders knows that. Why can't everyone figure that out?

George H. Blackford -> EMichael... , March 10, 2017 at 10:07 AM
Facts Liberal elites refuse to face:

a) In the 70s, a Dem congress began deregulating the financial system with the help of a Dem president.

b) In the 80s, a Dem congress continued deregulation and cut taxes on the rich, increased taxes on the not so rich, cut SS benefits and essential government programs, and abandoned the unions.

c) In the 90s, a Dem president reappointed Greenspan to the Fed, further deregulated and cut essential programs, and signed draconian crime, welfare, and student loan bills into law.

d) In 07, the Dems took back the congress and did nothing to hold accountable those who had led us into a war under false pretenses, turned us into a nation of torturers, and politicized the Justice Department as the concentration of income rose until the economy blew up in the fall of 08.

e) In 09 the Dems took complete control of the federal government and ignored students and homeowners as they bailed out the banks, passed a Heritage Foundation healthcare plan championed by the insurance and drug companies as incomes and wages plummeted.

The working and middle classes were decimated throughout this process, and, somehow, it's the voters' fault we ended up with a throw the bums out Trump instead of a more of the same Hillary? I don't think so!

Liberal elites are in a state of denial. It's time to wake up and face reality:
http://www.rweconomics.com/htm/Ch_1.htm
http://www.rweconomics.com/Deficit.htm
http://www.rweconomics.com/Sanders1.htm


pgl -> George H. Blackford ... , March 10, 2017 at 09:40 AM
Harris Wofford was a nobody in 1992 until he decided to take on the health care issue. And he shocked the world by beating one of the stars in the GOP machine. We should have had a real health care bill in 1993 but we failed. Obama sort of succeeded by dusting off the Republican plan. We need the next Harris Wofford.
Pinkybum -> George H. Blackford ... , March 10, 2017 at 08:43 AM
"The obvious solution for rising healthcare costs is either a public option or extending Medicare to younger and younger people, but Democrats, other than Sanders, refuse to offer or defend these solutions."

Medicare for all was not offered because politically it was a non-starter. The public option was offered and once the Republicans (and Democrats who might as well be Republicans) realized what it meant (out-competing insurance companies) they opposed it.

EMichael -> Pinkybum... , March 10, 2017 at 09:14 AM
oops, put this in the wrong place.

Nelson was the only Dem Senator that held his vote to end debate in order to get something. He was "paid off" and dropped his filibuster.

Lieberman, along with every Rep senator, stopped the public option.

Best part of the whole sorry process was the work of Pelosi, who took away Nelson's kickback through reconciliation. Something she could not do to Lieberman.

yuan -> Pinkybum... , March 10, 2017 at 09:32 AM
"and Democrats who might as well be Republicans"

people who try to equate these class traitors to all democrats are carrying their water.


[[House Speaker Nancy Pelosi (D-CA) pledged at the time that the House bill would include a public option.15 Indeed, a public option offered through a private insurance exchange was included in all three versions of the bill passed by House committees in the summer of 2009 (House Ways and Means and House Education and Labor on 17 July 2009; House Energy and Commerce on 31 July 2009), as well as in the bill passed by the full House of Representatives on 7 November 2009 (the Affordable Health Care for America Act, HR 3962). A public option was also included in the bill passed by the Senate Health, Education, Labor, and Pensions Committee on 15 July 2009 (the Affordable Health Choices Act, S 1679).

Senate Democrats were engaged in a highly contentious debate throughout the fall of 2009, and the political life of the public option changed almost daily. The debate reached a critical impasse in November 2009, when Sen. Joseph Lieberman (I-CT), who usually caucuses with the Democrats, threatened to filibuster the Senate bill if it included a public option.

Sen. Charles Schumer (D-NY) and Sen. Jay Rockefeller (D-WV) made last-minute attempts to introduce amendments to include a public option as the bill was about to be voted on by the Senate Finance Committee. Those failed, and there was no public option in either the bill that emerged from that committee or the bill that passed the full Senate on 24 December 2009]]

http://content.healthaffairs.org/content/29/6/1117.full

George H. Blackford -> yuan... , March 10, 2017 at 09:41 AM
My question is, why was this allowed to die there?

Why wasn't it raised as a campaign issue in the 2010, 2012, and 2014 elections, explained to the public, and fought for by the Democrats?

yuan -> George H. Blackford ... , March 10, 2017 at 09:47 AM
i think obama's conservatism played a huge role.
EMichael -> George H. Blackford ... , March 10, 2017 at 09:53 AM
It wasn't allowed to die there. It did die there.

Fairly easy to see that the election of a black man brought the GOP together in a way that nothing else could.

Dems took a beating in the mid terms, not because of the lack of a public option, but because of a black man in the white house. They could not run on further health care reform, cause that was not possible.

One thing.

Congress controls legislation. And to spit into the wind is stupid.

George H. Blackford -> EMichael... , March 10, 2017 at 10:11 AM
It died because the Democrats ran away from it in the 2010 election.
pgl -> Pinkybum... , March 10, 2017 at 09:43 AM
The Republicans have no ideas but they are very good at shutting down the best ideas for policy. Of course when people think of health care like they think about buying groceries getting past the GOP BS re market solutions needs louder and crispy messaging.
Jerry Brown : , March 10, 2017 at 06:46 AM
Part of me hopes the Republicans enact their dumb plan. It is not a good plan, not even as good as Obamacare which isn't all that great itself. But at least they will be on record for voting for it. Almost as soon as it goes into effect, it will be very obvious (even to many Republicans) that it needs to be fixed. At that point I am sure Democrats would be willing to help fix it. And if they don't fix it, their plan will crash, and then maybe we can enact real Health Care for Americans rather than subsidized premiums for insurance companies.

This plan is bad, and enacting it will be harmful to many Americans in the short term- but enacting it at least will affirm that even Republicans accept a role for government in the provision of health care.

Anachronism said in reply to Jerry Brown... , March 10, 2017 at 07:02 AM
You're correct that most people don't understand the abstract. They have to see it implemented in order to be able to say "Gee, this is horrible".

But when that happens, you now are inflicting a lot of pain on a lot of people who don't deserve it.

I like Will Rogers quote: "Some people can figure things out for themselves. Others learn by reading. The rest of the world needs to pee on the electric fence".

Jerry Brown said in reply to Anachronism ... , March 10, 2017 at 07:17 AM
Yes, it will inflict a lot of unnecessary pain on people, including me. And that is very unfortunate and should be considered criminal or at least sociopathic. And it should not be necessary. But I think that is what we will get out of this Congress and this President.

And then we may be able to fix it or even better scrap it for a Medicare for all type plan.

pgl -> Jerry Brown... , March 10, 2017 at 09:44 AM
It is a bad plan but given that we have been at this since Nixon, maybe the pain of this awful idea will finally wake people up. BTW - as bad a President as Nixon was, at least he wanted health care reform.
Fred C. Dobbs : , March 10, 2017 at 06:51 AM
(So there.)

How a Republican Obamacare replacement plan could
leave rural areas farther behind, from @fivefifths: https://www.theatlantic.com/politics/archive/2017/02/the-gop-plan-to-create-health-coverage-deserts/517839/
The Atlantic - Vann R. Newkirk II - Feb 28, 2017

The devil's always in the details, but if the details of a new 100-page leaked draft of a House Republican plan to repeal Obamacare are too dense to parse, here's a brief snapshot: Millions of people in rural areas where it's already hardest to find doctors might no longer be able to afford health insurance in a few years.

The basics of that plan, which was unveiled by House Speaker Paul Ryan two weeks ago, and the rough shape of which has the support of new health secretary Tom Price and the Trump administration, are known. The plan removes the individual and employer mandates to purchase and provide insurance, respectively, and it would also repeal most of the taxes that fund Obamacare. It would roll back funding for the Affordable Care Act's Medicaid expansion and dramatically restructure the Medicaid program's funding. Further, the plan would replace the Affordable Care Act's cost-sharing subsidies and premium tax credits with an age-rated tax credit, all while keeping Obamacare's popular pre-existing conditions ban.

With the leaked draft legislation released by Politico last week, there are more details as to exactly how House Republicans and the Trump administration plan to repeal Obamacare and usher in a replacement. The draft specifies that Obamacare's Medicaid expansion for low-income able-bodied adults won't be completely eliminated, but the eligibility and funding will be rolled back after 2020. The draft also contains a provision changing federal funding for Medicaid in 2020 onward from an open-ended obligation to a system where the per-person spending every year is capped based on spending levels in 2019 and increased annually to correspond with medical inflation.

Although the draft plan repeals the tax-based individual mandate, it re-establishes a kind of mandate through its incentive to maintain continuous health-insurance coverage. For people not covered by employers or public insurance who have to purchase insurance on individual, small group, or exchange markets, this proposal would allow insurers to charge up to 30 percent more in premiums to people who go without coverage at any point for more than two months, and also for young adults who don't enroll in coverage as soon as they age out of their parents' plans, a surcharge that would not be remitted as taxes to sustain the system, but would be paid as profits to insurers. The effects of this potential measure on individuals' pockets are potentially limited by a reduction of federal oversight over what can be considered health-insurance coverage, which would allow people to avoid penalties by purchasing barebones coverage.

After reforming Medicaid, repealing the taxes and mandates of Obamacare and establishing continuous-coverage requirements, the last major reform of this preliminary scheme is to replace the cost-sharing reductions and premium tax credit subsidies of Obamacare's exchanges with a refundable tax credit. Unlike the Obamacare tax credit, which is adjusted by income, age, and the average price of insurance in a person's market, this new credit would only take age into account, starting with $2,000 per year up to age 30 and capping at $4,000 for people over 60. So while older people with more health needs receive more than "young invincibles," lower-income people who tend to have more pressing health needs would have even less ability to take care of those needs given their existing ability to pay.

The result of all these provisions would almost certainly be a system that benefits people who already have wealth and health and penalizes others, but there would also be very strong geographic effects. For one, pegging Medicaid spending to a base year would reduce states' ability to ramp up health-care spending because of disasters or emerging health problems, and these problems already exert the most pressures on states and areas with infrastructure that is ill-equipped to combat them. Rural residents already rely much more heavily on public insurance than do city-dwellers, so any reductions of funding and funding flexibility will have a larger effect on the health issues they face. ...

The tax-credit structure in the Republican draft plan might be even more damaging than the Medicaid changes to those underserved and rural areas. The existing Obamacare tax credits are not only adjusted by family income, but also by the actual cost of health-care plans in a given market. That geographic adjustment is one of the most important parts of the basic logic of Obamacare, since health-care costs vary quite a bit from place to place.

In the most extreme example, Alaskans in the Obamacare exchanges currently receive tax credits at rates double the average for the rest of the country, a number that reflects the scarcity of coverage in Alaska and the demands of covering a frontier population. The Republican proposal might knock all 16,000 of these Alaskans out of insurance markets. ...

Fred C. Dobbs said in reply to Fred C. Dobbs... , March 10, 2017 at 06:55 AM
A tax-credit plan that doesn't account for the actual cost of a person's health insurance might reasonably be expected to create areas where coverage is simply unaffordable, and not just in Alaska. Research indicates that health-insurance premiums are higher for rural counties and states, particularly towards the interior and western frontier of the country-prime Trump country. Those costs increase even as rural residents have less access to basic health care and worse overall health status than their metropolitan peers.

That disparity between costs and access for rural residents creates a conundrum for Republicans. By reducing state Medicaid financial flexibility, reducing oversight over minimum insurance requirements, instilling continuous coverage requirements, and removing regional costs offsets, their Obamacare replacement would in essence put health insurance even further out of reach for sicker, rural patients who need it more and then penalize them for being left out. These patients already suffer the effects of "health-care deserts" as rural hospital systems collapse and access to basic specialty services like maternal care wane. In addition to those health care and service deserts in rural areas, Republicans would be contributing to brand-new "coverage deserts."

The result might be a national health-insurance system that does relatively well for so-called "coastal elites" with decent access to physicians and robust state public-health infrastructure, but rather badly for the denizens of Middle America that Trump and the GOP place at the center of their rhetoric. As more and more Republican congressmen in those places face hostile town halls about Obamacare and a real fear of losing coverage from constituents, this new policy outline doesn't seem likely to alleviate those fears.

sanjait -> Fred C. Dobbs... , March 10, 2017 at 10:14 AM
Didn't read past the heading ... but yes, rural residents would be screwed by the GOP's bill.

Rural residents are more likely to be receiving subsidies under the expanded Medicaid and exchanges.

Perhaps worse,*rural hospitals* are always hanging on by a thread, and when more of their patients are uninsured that tips the balance toward insolvency for them. The American Health Carnage Act would result in significantly reduced access to healthcare for rural residents, because geography.

Fred C. Dobbs : , March 10, 2017 at 07:35 AM
BLUEXIT

A Modest Proposal For Separating Blue States From Red

The New Republic - KEVIN BAKER - March 9, 2017

https://newrepublic.com/article/140948/bluexit-blue-states-exit-trump-red-america

Dear Red-State Trump Voter,

Let's face it, guys: We're done.

For more than 80 years now, we-the residents of what some people like to call Blue America, but which I prefer to think of as the United States of We Pay Our Own Damn Way-have shelled out far more in federal tax monies than we took in. We have funded massive infrastructure projects in your rural counties, subsidized your schools and your power plants and your nursing homes, sent you entire industries, and simultaneously absorbed the most destitute, unskilled, and oppressed portions of your populations, white and black alike.

All of which, it turns out, only left you more bitter, white, and alt-right than ever.

Some folks here in self-supporting America like to believe that there must be a way to bring you back to your senses and to restore rational government, if not liberal ideals, sometime in the foreseeable future. Everyone seems to have an answer for how to do this. Every day another earnest little homily finds its way to me over my internet transom: "Think locally, act globally," or "Make art and fight the power," or the old Joe Hill standby-"Don't mourn. Organize."

To which I say: Don't organize. Pack.

Not literally, of course. Not even the good people of Canada should have to stomach a mass migration of moping American liberals mumbling, "Live locally make art." What I mean is that it's time for blue states and cities to effectively abandon the American national enterprise, as it is currently constituted. Call it the New Federalism. Or Virtual Secession. Or Conscious Uncoupling-though that's already been used. Or maybe Bluexit.

Truth is, you red states just haven't been pulling your weight. Not for, well, forever. Red states are nearly twice as dependent on the federal government as blue states. Of the twelve states that received the least federal aid in return for each tax dollar they contribute to the U.S. Treasury, ten of them voted for Hillary Clinton-and the other two were Michigan and Wisconsin, your newest recruits. By the same count, 20 of the 26 states most dependent on federal aid went to Trump.

Take Mississippi (please!), famous for being 49th or 50th in just about everything that matters. When it comes to sucking at the federal teat, the Magnolia State is the undisputed champ. More than 40 percent of Mississippi's state revenue comes from federal funding; one-third of its GDP comes from federal spending; for every dollar it pays out in federal taxes, it takes in $4.70 in federal aid; one in five residents are on food stamps-all national highs. You people-your phrase, not mine-liked to bash Obama for turning America into what you derisively referred to as "Food Stamp Nation." In reality, it's more like Food Stamp Red America-something your Trump-loving congressmen will discover if and when they fulfill their vow to gut the program.

Trump's characterization of "American carnage" in our urban centers aside, cities now generate the vast majority of America's wealth-the cities, that is, where blue folks live. It's true that Hillary Clinton carried just 487 counties in 2016. It's also true that those 487 counties generate almost two-thirds of the nation's economic activity. ...

Fred C. Dobbs said in reply to Fred C. Dobbs... , March 10, 2017 at 07:39 AM
Except for California (a big
exception), Red states are
where most of our food
comes from, yes?

Hmmm.

yuan -> Fred C. Dobbs... , March 10, 2017 at 09:34 AM
i guess you have never visited oregon and washington.
Fred C. Dobbs said in reply to yuan... , March 10, 2017 at 09:59 AM
Actually, I have, if briefly.
The home of Harry & David.

They may have to keep us alive.

New Deal democrat said in reply to Fred C. Dobbs... , March 10, 2017 at 08:13 AM
The Constitution does allow Interstate Compacts, and it is high time the blue states banded together to offer social insurance via that route.

It would also be fun to talk up an "Interstate Balanced Budget Amendment" enacting Baker's proposition, just for the shits and giggles of watching the red states squirm.

llisa2u2 : , March 10, 2017 at 09:25 AM
"But the answer, of course, is that they were all lying, all along - and they still are. On this, at least, Republican unity remains impressively intact."

What a shame that there really is no integrity in this "replace" process.

MSM, CSPAN discussions and townhall meetings need to address and compare specific medical scenario examples as to "What will be the real costs to the American Citizen".. What options will the American Citizen have to consider for coverage and at what price? Discussions have been so superficial, and just rehashing trite to simplistic process, and primarily Ryan's Powerpoint presentation. Probably the only real take-away from his presentation is the fact that he spoke with his shirt-sleeves rolled up!

How about comparisons as to costs for coverage for what medical services that citizens pay in England, Canada, Germany, France, Switzerland, Norway, Denmark, Sweden, Spain?
How much does a specific drug cost in those countries versus in the US? There is absolutely no addressing the reality of annual costs to the American Citizen and what he/she is paying for. Presently my superficial takeaway is I presume that the majority of citizens will be paying annually $6,000 just for the right to say they have paid for the right to have access to any kind of medical insurance, then there will be various options for any kind of real coverage for specific procedures and services....

The Dems and Repubs and everybody else needs to cut the BS!
Quit talking about nothing! Put some real cut and dry facts out to LaLaLand....

llisa2u2 : , March 10, 2017 at 09:32 AM
Every member of Congress, retiree of Congress, President, and past president, every Federal and State employee needs to be under exactly the same coverage options, with no exceptions to entitled separate "exclusive" coverage as governmental employees, as all other American citizens.
Sanjait : , March 10, 2017 at 09:36 AM
The GOP plan makes perfect sense when you realize it was designed with talking points in mind, rather than impact.

They replaced the mandate with "responsibility", replaced coverage standards with "choice", put in block grants because "states rights" and "flexibility," and delayed the onset of spending cuts because "stability."

It was a strategy, just not an effective one. few people right now are buying their talking points, so it just looks like a "WTF?" situation.

DrDick -> Sanjait... , March 10, 2017 at 10:50 AM
Governance by talking point.
DeDude : , March 10, 2017 at 09:38 AM
How about allowing everybody to buy into Medicare, Medicaid, VA or congresses own health insurance plan - with subsidies to those who cannot afford it. Those programs are the most cost-effective in all of US. If the private sector want to provide something more cost effective it would be welcome to do so in a direct competition. What could be more market based and efficient than that?
RC AKA Darryl, Ron said in reply to DeDude... , March 10, 2017 at 10:22 AM
The VA healthcare plan is about the same as the Republican plan. If you can afford to live in or travel to Bethesda MD then you may live. Otherwise, costs are controlled by a mortality expectation that is shorter than wait time.
im1dc : , March 10, 2017 at 09:43 AM
PK: "the modern G.O.P. always wants to comfort the comfortable and afflict the afflicted; so the bill ends up throwing away the taxes on the rich that help pay for subsidies, and redirects the subsidies themselves away from those who need them to those who don't."

Absolutely loved reading this expose of the GOP in D.C.

yuan -> im1dc... , March 10, 2017 at 09:49 AM
it's an accurate description, imo. funny how the so called "liberal media" can't find the courage to use similarly honest language.
im1dc : , March 10, 2017 at 10:11 AM
Something I have noticed in my neighborhood in Deep Red Tennessee is that Trump Supporters really want Obamacare repealed and not replaced BUT almost to a person these are people who have either Federal or State funded Health Insurance or Medicare.

IOW, they got theirs and expect everyone else to get theirs from the Tooth Fairy like they think they got theirs.

Fred C. Dobbs said in reply to im1dc... , March 10, 2017 at 11:01 AM
Indeed. Folks who feel that
have worked hard in their
lives believe they are entitled,
and those who haven't - for
whatever reasons - are not.

Which takes little account of
those who have been severely
disadvantaged over many years.

Fred C. Dobbs : , March 10, 2017 at 10:57 AM
It has been noted that many of those
who voted for Mr Trump are opposed
to providing medical benefits for
those they regard as 'freeloaders'.

Also, those in the Red states seem
to be opposed to basing benefit amounts
in favor of those Blue staters who have
extra-expensive medical care.

Clearly, the Ryan-Trump plan deals with both issues.

And will further jeopardize healthcare in
a lot of GOP-supporting areas, ironically.

(I'd bet something is going to be
done to fix that anomaly.)

[Mar 10, 2017] Funny how the so called liberal media cant find the courage to use similarly honest language: the bill ends up throwing away the taxes on the rich that help pay for subsidies, and redirects the subsidies themselves away from those who need them to those who don't.

Notable quotes:
"... the bill ends up throwing away the taxes on the rich that help pay for subsidies, and redirects the subsidies themselves away from those who need them to those who don't." ..."
"... Something I have noticed in my neighborhood in Deep Red Tennessee is that Trump Supporters really want Obamacare repealed and not replaced BUT almost to a person these are people who have either Federal or State funded Health Insurance or Medicare. IOW, they got theirs and expect everyone else to get theirs from the Tooth Fairy like they think they got theirs. ..."
"... Envy as a sister of competition story ;-) ..."
"... As someone said the other day on the intertubes, this is an upper class tax cut funded by eliminating healthcare for the poor. ..."
Mar 10, 2017 | economistsview.typepad.com
im1dc : March 10, 2017 at 09:43 AM
PK: "the modern G.O.P. always wants to comfort the comfortable and afflict the afflicted; so the bill ends up throwing away the taxes on the rich that help pay for subsidies, and redirects the subsidies themselves away from those who need them to those who don't."

Absolutely loved reading this expose of the GOP in D.C.

yuan -> im1dc... , March 10, 2017 at 09:49 AM
it's an accurate description, imo. funny how the so called "liberal media" can't find the courage to use similarly honest language.
im1dc : ,
Something I have noticed in my neighborhood in Deep Red Tennessee is that Trump Supporters really want Obamacare repealed and not replaced BUT almost to a person these are people who have either Federal or State funded Health Insurance or Medicare. IOW, they got theirs and expect everyone else to get theirs from the Tooth Fairy like they think they got theirs.
libezkova -> im1dc... , March 10, 2017 at 01:52 PM
Envy as a sister of competition story ;-)
Fred C. Dobbs -> im1dc... , March 10, 2017 at 11:01 AM
Indeed. Folks who feel that
have worked hard in their
lives believe they are entitled,
and those who haven't - for
whatever reasons - are not.

Which takes little account of
those who have been severely
disadvantaged over many years.

DrDick : , March 10, 2017 at 11:34 AM
As someone said the other day on the intertubes, this is an upper class tax cut funded by eliminating healthcare for the poor.

[Mar 10, 2017] All this neoliberals cries about deficiencies of Trumpcare plan are just crocodile tears

Notable quotes:
"... my falling out with the Democratic Party goes back to at least 1968, with concerns even earlier when I was still a school kid. ..."
"... Power corrupts is one of the immutable laws of economics. Democracy is not a good spectator sport. ..."
Mar 10, 2017 | economistsview.typepad.com
libezkova -> ilsm... March 10, 2017 at 05:01 PM
I like the guys who first created meth epidemic in the US and now shed crocodile tears about deficiencies of Obamacare replacement.

RC AKA Darryl, Ron : March 10, 2017 at 03:08 PM , 2017 at 03:08 PM

Why did Republicans propose a "sick joke of a health plan"?

[I am guessing that is a rhetorical question. Just saying that the Republican Party is a sick joke of a political party is both too easy and too obvious.]

libezkova -> RC AKA Darryl, Ron... March 10, 2017 at 05:23 PM , 2017 at 05:23 PM
The problem is not that "the Republican Party is a sick joke of a political party". That's given. Just look at McCain and friends.

The problem is that the Democratic Party became the same sick joke. Even slightly sicker in some respects as they more rely on betrayal of voters and bait and switch tactics pursuing the same neoliberal policies.

Republicans were neoliberal party, the party of big business for a long time. They gave us Reagan and Bush II. But Democrats became the party of Wall Street relatively recently during Clinton presidency.

Get people decent jobs and healthcare plan issues might be more solvable. Institute higher minimal wage as a start. Tax neoliberal "masters of the universe" (and especially the strata of Wall Street speculators and Buffet wannabees ) at Eisenhower rates and put those money into national health insurance fund for everybody, providing for "catastrophic insurance" for a start.

Destroy at least a part of sick, criminal links between medical insurance and for profit hospitals using RICO statute. They are really a new type of mafia. All those useless stent surgeries are not that different from shooting people on the street.

But redistribution policies are a taboo under neoliberalism, so DemoRats will just complain about Trumpcare and than support Republicans in enacting it. The same story as before. Vichy DemoRats will always remain Vichy DemoRats.

If you have no money for both apartment and food like many Wal-Mart workers (living on foodstamps) I doubt that you can pay for health insurance either. So for really poor folks Obamacare was a sick joke. It really was. Obama sold himself to medical-industrial complex which is no less vicious and greedy the military industrial complex.

So all this neoliberals cries about deficiencies of Trumpcare plan are just crocodile tears.

RC AKA Darryl, Ron -> libezkova... March 10, 2017 at 05:32 PM , 2017 at 05:32 PM
That was a bit harsh but there is more than a grain of truth in it. It is late now and I don't have the time now to go into a more measured accounting of how we got from the New Deal to here, but my falling out with the Democratic Party goes back to at least 1968, with concerns even earlier when I was still a school kid.

Power corrupts is one of the immutable laws of economics. Democracy is not a good spectator sport.

[Mar 10, 2017] How a Republican Obamacare replacement plan could leave rural areas farther behind

Notable quotes:
"... Unlike the Obamacare tax credit, which is adjusted by income, age, and the average price of insurance in a person's market, this new credit would only take age into account, starting with $2,000 per year up to age 30 and capping at $4,000 for people over 60. ..."
"... The result of all these provisions would almost certainly be a system that benefits people who already have wealth and health and penalizes others, but there would also be very strong geographic effects. For one, pegging Medicaid spending to a base year would reduce states' ability to ramp up health-care spending because of disasters or emerging health problems, and these problems already exert the most pressures on states and areas with infrastructure that is ill-equipped to combat them. Rural residents already rely much more heavily on public insurance than do city-dwellers, so any reductions of funding and funding flexibility will have a larger effect on the health issues they face. ... ..."
"... he most extreme example, Alaskans in the Obamacare exchanges currently receive tax credits at rates double the average for the rest of the country, a number that reflects the scarcity of coverage in Alaska and the demands of covering a frontier population. The Republican proposal might knock all 16,000 of these Alaskans out of insurance markets. ... ..."
"... Those costs increase even as rural residents have less access to basic health care and worse overall health status than their metropolitan peers. ..."
Mar 10, 2017 | economistsview.typepad.com
Fred C. Dobbs : March 10, 2017 at 06:51 AM , 2017 at 06:51 AM
(So there.)

How a Republican Obamacare replacement plan could leave rural areas farther behind, from @fivefifths: https://www.theatlantic.com/politics/archive/2017/02/the-gop-plan-to-create-health-coverage-deserts/517839/
The Atlantic - Vann R. Newkirk II - Feb 28, 2017

The devil's always in the details, but if the details of a new 100-page leaked draft of a House Republican plan to repeal Obamacare are too dense to parse, here's a brief snapshot: Millions of people in rural areas where it's already hardest to find doctors might no longer be able to afford health insurance in a few years.

The basics of that plan, which was unveiled by House Speaker Paul Ryan two weeks ago, and the rough shape of which has the support of new health secretary Tom Price and the Trump administration, are known. The plan removes the individual and employer mandates to purchase and provide insurance, respectively, and it would also repeal most of the taxes that fund Obamacare. It would roll back funding for the Affordable Care Act's Medicaid expansion and dramatically restructure the Medicaid program's funding. Further, the plan would replace the Affordable Care Act's cost-sharing subsidies and premium tax credits with an age-rated tax credit, all while keeping Obamacare's popular pre-existing conditions ban.

With the leaked draft legislation released by Politico last week, there are more details as to exactly how House Republicans and the Trump administration plan to repeal Obamacare and usher in a replacement. The draft specifies that Obamacare's Medicaid expansion for low-income able-bodied adults won't be completely eliminated, but the eligibility and funding will be rolled back after 2020. The draft also contains a provision changing federal funding for Medicaid in 2020 onward from an open-ended obligation to a system where the per-person spending every year is capped based on spending levels in 2019 and increased annually to correspond with medical inflation.

Although the draft plan repeals the tax-based individual mandate, it re-establishes a kind of mandate through its incentive to maintain continuous health-insurance coverage. For people not covered by employers or public insurance who have to purchase insurance on individual, small group, or exchange markets, this proposal would allow insurers to charge up to 30 percent more in premiums to people who go without coverage at any point for more than two months, and also for young adults who don't enroll in coverage as soon as they age out of their parents' plans, a surcharge that would not be remitted as taxes to sustain the system, but would be paid as profits to insurers. The effects of this potential measure on individuals' pockets are potentially limited by a reduction of federal oversight over what can be considered health-insurance coverage, which would allow people to avoid penalties by purchasing barebones coverage.

After reforming Medicaid, repealing the taxes and mandates of Obamacare and establishing continuous-coverage requirements, the last major reform of this preliminary scheme is to replace the cost-sharing reductions and premium tax credit subsidies of Obamacare's exchanges with a refundable tax credit. Unlike the Obamacare tax credit, which is adjusted by income, age, and the average price of insurance in a person's market, this new credit would only take age into account, starting with $2,000 per year up to age 30 and capping at $4,000 for people over 60. So while older people with more health needs receive more than "young invincibles," lower-income people who tend to have more pressing health needs would have even less ability to take care of those needs given their existing ability to pay.

The result of all these provisions would almost certainly be a system that benefits people who already have wealth and health and penalizes others, but there would also be very strong geographic effects. For one, pegging Medicaid spending to a base year would reduce states' ability to ramp up health-care spending because of disasters or emerging health problems, and these problems already exert the most pressures on states and areas with infrastructure that is ill-equipped to combat them. Rural residents already rely much more heavily on public insurance than do city-dwellers, so any reductions of funding and funding flexibility will have a larger effect on the health issues they face. ...

The tax-credit structure in the Republican draft plan might be even more damaging than the Medicaid changes to those underserved and rural areas. The existing Obamacare tax credits are not only adjusted by family income, but also by the actual cost of health-care plans in a given market. That geographic adjustment is one of the most important parts of the basic logic of Obamacare, since health-care costs vary quite a bit from place to place.

In the most extreme example, Alaskans in the Obamacare exchanges currently receive tax credits at rates double the average for the rest of the country, a number that reflects the scarcity of coverage in Alaska and the demands of covering a frontier population. The Republican proposal might knock all 16,000 of these Alaskans out of insurance markets. ...

Fred C. Dobbs -> Fred C. Dobbs... , March 10, 2017 at 06:55 AM
A tax-credit plan that doesn't account for the actual cost of a person's health insurance might reasonably be expected to create areas where coverage is simply unaffordable, and not just in Alaska. Research indicates that health-insurance premiums are higher for rural counties and states, particularly towards the interior and western frontier of the country-prime Trump country. Those costs increase even as rural residents have less access to basic health care and worse overall health status than their metropolitan peers.

That disparity between costs and access for rural residents creates a conundrum for Republicans. By reducing state Medicaid financial flexibility, reducing oversight over minimum insurance requirements, instilling continuous coverage requirements, and removing regional costs offsets, their Obamacare replacement would in essence put health insurance even further out of reach for sicker, rural patients who need it more and then penalize them for being left out. These patients already suffer the effects of "health-care deserts" as rural hospital systems collapse and access to basic specialty services like maternal care wane. In addition to those health care and service deserts in rural areas, Republicans would be contributing to brand-new "coverage deserts."

The result might be a national health-insurance system that does relatively well for so-called "coastal elites" with decent access to physicians and robust state public-health infrastructure, but rather badly for the denizens of Middle America that Trump and the GOP place at the center of their rhetoric. As more and more Republican congressmen in those places face hostile town halls about Obamacare and a real fear of losing coverage from constituents, this new policy outline doesn't seem likely to alleviate those fears.

[Mar 10, 2017] Neoliberals replaced the mandate with responsibility , replaced coverage standards with muckk worce choice , put in block grants because of states rights and flexibility, and delayed the onset of spending cuts because stability.

Notable quotes:
"... But the answer, of course, is that they were all lying, all along - and they still are. ..."
"... MSM, CSPAN discussions and townhall meetings need to address and compare specific medical scenario examples as to "What will be the real costs to the American Citizen".. ..."
"... Discussions have been so superficial, and just rehashing trite to simplistic process, and primarily Ryan's Powerpoint presentation. Probably the only real take-away from his presentation is the fact that he spoke with his shirt-sleeves rolled up! ..."
"... How much does a specific drug cost in those countries versus in the US? There is absolutely no addressing the reality of annual costs to the American Citizen and what he/she is paying for. Presently my superficial takeaway is I presume that the majority of citizens will be paying annually $6,000 just for the right to say they have paid for the right to have access to any kind of medical insurance, then there will be various options for any kind of real coverage for specific procedures and services.... ..."
"... The Dems and Repubs and everybody else needs to cut the BS! Quit talking about nothing! Put some real cut and dry facts out to LaLaLand.... ..."
"... Every member of Congress, retiree of Congress, President, and past president, every Federal and State employee needs to be under exactly the same coverage options, with no exceptions to entitled separate "exclusive" coverage as governmental employees, as all other American citizens. ..."
Mar 10, 2017 | economistsview.typepad.com

sanjait : March 10, 2017 at 09:36 AM , 2017 at 09:36 AM

The GOP plan makes perfect sense when you realize it was designed with talking points in mind, rather than impact.

They replaced the mandate with "responsibility", replaced coverage standards with "choice", put in block grants because "states rights" and "flexibility," and delayed the onset of spending cuts because "stability."

It was a strategy, just not an effective one. few people right now are buying their talking points, so it just looks like a "WTF?" situation.

llisa2u2 : March 10, 2017 at 09:25 AM , 2017 at 09:25 AM
"But the answer, of course, is that they were all lying, all along - and they still are. On this, at least, Republican unity remains impressively intact."

What a shame that there really is no integrity in this "replace" process.

MSM, CSPAN discussions and townhall meetings need to address and compare specific medical scenario examples as to "What will be the real costs to the American Citizen".. What options will the American Citizen have to consider for coverage and at what price?

Discussions have been so superficial, and just rehashing trite to simplistic process, and primarily Ryan's Powerpoint presentation. Probably the only real take-away from his presentation is the fact that he spoke with his shirt-sleeves rolled up!

How about comparisons as to costs for coverage for what medical services that citizens pay in England, Canada, Germany, France, Switzerland, Norway, Denmark, Sweden, Spain?

How much does a specific drug cost in those countries versus in the US? There is absolutely no addressing the reality of annual costs to the American Citizen and what he/she is paying for. Presently my superficial takeaway is I presume that the majority of citizens will be paying annually $6,000 just for the right to say they have paid for the right to have access to any kind of medical insurance, then there will be various options for any kind of real coverage for specific procedures and services....

The Dems and Repubs and everybody else needs to cut the BS! Quit talking about nothing! Put some real cut and dry facts out to LaLaLand....

llisa2u2 : March 10, 2017 at 09:32 AM , 2017 at 09:32 AM
Every member of Congress, retiree of Congress, President, and past president, every Federal and State employee needs to be under exactly the same coverage options, with no exceptions to entitled separate "exclusive" coverage as governmental employees, as all other American citizens.

[Mar 10, 2017] This is not an act of mercy. It is an act of malice

Mar 10, 2017 | economistsview.typepad.com
Fred C. Dobbs : March 09, 2017 at 01:49 PM , 2017 at 01:49 PM
Ryan defends health care bill amid fierce protest
http://www.bostonglobe.com/news/politics/2017/03/08/house-committees-convene-over-controversial-health-care-law/6LfoZ7S1GBh5cEO4EhV7KJ/story.html?event=event25
via @BostonGlobe - March 8

WASHINGTON (AP) - Speaker Paul Ryan staunchly defended the House Republican health care plan Wednesday as the only alternative to the current Obama-era law, as he confronted forceful opposition from conservatives, medical professionals and others.

''This is the choice we face. Are we going to stay with Obamacare ... or are we going to do what we said we would do,'' Ryan said at a Capitol Hill news conference after a private GOP meeting in which he tried to rally support.

Shortly after Ryan's comments, two committees - Ways and Means and Energy and Commerce - kicked off what are expected to be marathon sessions to finalize the legislation that would scrap major parts of Barack Obama's health overhaul while also fundamentally restructuring Medicaid for low-income people.

Democrats resorted to delaying tactics. At Energy and Commerce, the clerk was forced to start reading the legislation word for word after Rep. Ben Lujan, D-N.M., objected to routinely dispensing with such a reading. At Ways and Means, Republicans voted down a motion by Rep. Lloyd Doggett, D-Texas, to delay deliberations so lawmakers could have more time to study the bill.

Ryan cast the task for the GOP as fulfilling seven years of promises to ''repeal and replace'' with a ''conservative wish list'' scaling back the role of government in health care, cutting money for Planned Parenthood and overhauling mandatory programs.

''Most importantly, we get Washington out of the business of being a nanny state,'' he said.

President Donald Trump and Vice President Mike Pence back the House plan, and Ryan is confidently predicting it will win passage. Behind closed doors on Wednesday, Ryan pointedly told fellow lawmakers that the president is all-in and suggested they should fall in line. ...

Joe Kennedy III attacks GOP health plan for its 'malice'
http://www.bostonglobe.com/metro/2017/03/08/kennedy-rips-gop-health-plan/IWpUdBxaIrjA50ooQ1z43J/story.html?event=event25
via @BostonGlobe - Joshua Miller - March 8, 2017

US Representative Joe Kennedy III ripped into the House GOP's plan to repeal the Affordable Care Act Wednesday in a surprisingly pointed jibe at Speaker Paul Ryan.

Ryan said Tuesday that Republicans are "doing an act of mercy" by repealing the law known as Obamacare and replacing it with something else.

Kennedy, shall we say, does not share that assessment.

"I was struck last night by a comment that I heard made by Speaker Ryan, where he called this repeal bill 'an act of mercy.' With all due respect to our speaker, he and I must have read different Scripture," Kennedy said as the House Energy and Commerce Committee dove into the details of the GOP effort.

"The one I read calls on us to feed the hungry, to clothe the naked, to shelter the homeless, and to comfort the sick.

"It reminds us that we are judged not by how we treat the powerful, but by how we care for the least among us," said the Brookline Democrat and scion of the most famous Massachusetts political dynasty.

"There is no mercy in a system that makes health care a luxury. There is no mercy in a country that turns their back on those most in need of protection: the elderly, the poor, the sick, and the suffering. There is no mercy in a cold shoulder to the mentally ill," he said, appearing to read from notes.

"This is not an act of mercy. It is an act of malice," he said. ...

Senator Warren says GOP health care plan is 'fundamentally cruel'
http://www.bostonglobe.com/metro/2017/03/09/senator-warren-says-gop-health-care-plan-fundamentally-cruel/UOwTdHl3KFloausjuGQK0H/story.html?event=event25
via @BostonGlobe - March 9

BOSTON (AP) - Sen. Elizabeth Warren says the health care bill rolled out by Republicans is ''fundamentally cruel'' and will end up benefiting the wealthy at the expense of middle and working class families.

The Massachusetts Democrat said Wednesday that Republicans seem more interested in bragging about getting rid of ''Obamacare'' than helping people stay healthy.

Warren says the GOP plan will ''work great for those at the top and just kick dirt in the faces of everybody else.'' ...


anne : , March 09, 2017 at 01:54 PM
http://www.oecd.org/health/health-systems/oecd-health-statistics-2014-frequently-requested-data.htm

November, 2016

Organisation for Economic Co-operation and Development Health Data

Total health care spending per person, 2014 *

United States ( 9451)
OCED average ( 3814)

Australia ( 4420)
Austria ( 5016)
Belgium ( 4611)
Canada ( 4608)
Chile ( 1728)
Czech Republic ( 2464)
Denmark ( 4943)
Finland ( 3984)
France ( 4407)
Germany ( 5267)
Greece ( 2245)
Hungary ( 1845)
Iceland ( 4012)
Ireland ( 5131)
Israel ( 2533)
Italy ( 3272)
Japan ( 4150)
Korea ( 2488)
Luxembourg ( 7765)
Mexico ( 1052)
Netherlands ( 5343)
New Zealand ( 3590)
Norway ( 6567)
Poland ( 1677)
Portugal ( 2631)
Slovak Republic ( 2064)
Spain ( 3153)
Sweden ( 5228)
Switzerland ( 6935)
Turkey ( 1064)
United Kingdom ( 4003)

* Data are expressed in US dollars adjusted for purchasing power parities (PPPs), which provide a means of comparing spending between countries on a common base. PPPs are the rates of currency conversion that equalise the cost of a given "basket" of goods and services in different countries.

anne -> anne... , March 09, 2017 at 02:04 PM
Correcting date for data:

http://www.oecd.org/health/health-systems/oecd-health-statistics-2014-frequently-requested-data.htm

November, 2016

Organisation for Economic Co-operation and Development Health Data

Total health care spending per person, 2015 *

[Mar 09, 2017] The case for Single Payer just go stronger

Mar 09, 2017 | economistsview.typepad.com
im1dc : March 09, 2017 at 02:25 PM , 2017 at 02:25 PM
The case for Single Payer just go stronger

http://www.huffingtonpost.com/entry/insurance-companies-medicare-for-all_us_58c1b1fae4b054a0ea690dc8

"Insurance Companies Just Accidentally Made The Case For Medicare For All"

'It's all about the overhead and profit'

By Daniel Marans...03/09/2017...03:51 pm ET...Updated 23 minutes ago

"America's Health Insurance Plans, the trade group for commercial health insurance companies, published an infographic this month breaking down how the industry spends every dollar it receives in premiums.

The group apparently crafted the visual aid to defend rising premiums its member companies are charging customers.

But the chart also inadvertently helps explain why commercial health insurance is a bad deal.

The graphic shows that about 80 percent of every premium dollar goes toward medical expenses ― prescription drugs, doctor visits, hospitalization and other services. Approximately 18 percent goes to administrative costs, and some 3 percent is profit. (The total is more than 100 percent because of rounding. America's Health Insurance Plans explains how it gathered the figures for its infographic here... https://ahip.org/health-care-dollar/

Graphic 'Premium Dollar Breakdown'

By contrast, Medicare, the largest U.S. public insurer, paid just 1.5 percent of its budget to administer traditional insurance plans for seniors and workers with severe disabilities in 2015, according to official data. The rest of Medicare's budget went to paying doctors, hospitals, drug companies and other health care providers.

When you account for administrative costs of Medicare's private plans, which cover some one-third of Medicare beneficiaries, Medicare's overhead approaches 6.4 percent of its budget.

The comparison shows that expanding Medicare to cover the entire population ― or adopting a single-payer health insurance system ― would significantly reduce health care costs by eliminating a whole lot of expenses that aren't related to medical care. That's in part because Medicare does not have to advertise its services, make a profit for investors, or reward its executives with multi-million-dollar compensation packages, as private insurers do.

If the Republican health care replacement law takes effect, it could encourage companies to jack up executive pay even higher. The legislation would raise limits on how much executive compensation a company can deduct from taxes.

Some critics claim the Medicare figures are misleading, because the government insurance program benefits from Social Security Administration and Internal Revenue Service help in collecting the taxes it needs to fund its operations.

In fact, Medicare reimburses the other federal agencies for their services, according to Paul Van de Water, a senior fellow at the liberal Center on Budget & Policy Priorities.

"The notion that there are all these federal costs that are not accounted for is absolutely positively false," Van de Water said.

There are risks and tradeoffs of a single-payer system, like the possibility that insurance coverage will provide fewer benefits than the private insurance market, according to Austin Frakt, a health economist for the Department of Veterans Affairs with academic posts at Boston University and Harvard.

And there are other systems for bringing down costs, like all-payer rate setting, which allows multiple insurers to negotiate provider prices as a single unit, Frakt added.

But "if you look just at cost control, you almost can't do better than single payer," Frakt said.

Thanks, America's Health Insurance Plans!"

[Mar 09, 2017] The roak from Obama care to Trumpcare is full or traps

Mar 09, 2017 | economistsview.typepad.com
anne : March 09, 2017 at 02:18 PM , 2017 at 02:18 PM
http://www.pnhp.org/news/2017/march/pnhp-on-gops-re-branded-and-far-meaner-version-of-aca

March 8, 2017

Physicians for a National Health Program on GOP's re-branded and far meaner version of ACA

The 'American Health Care Act' perpetuates the basic structure of the Affordable Care Act, including the subsidization of the private health insurance industry, while cutting benefits to the poor and middle class, and giving hundreds of billions in tax breaks to the rich

Proposed as a replacement of the Affordable Care Act (ACA), the AHCA would maintain its basic structure. The bill would:

• Continue to channel billions of taxpayer dollars through wasteful private insurers;

• Sharply reduce the ACA's subsidies (or "tax credits") available to lower-income persons, particularly older adults, to purchase coverage;

• End the ACA's cost-sharing subsidies for copayments and deductibles, increasing the cost of care for those with chronic medical conditions;

• Replace the ACA's "individual mandate" penalty on the uninsured with a 30 percent surcharge on insurance premiums for those who experienced a lapse in insurance coverage;

• Slash federal funding for the Medicaid expansion beginning in 2020, and move towards a "per capita" cap on Medicaid spending that would squeeze state Medicaid budgets and push millions of enrollees out of the program;

• Increase the tax-favored status of Health Savings Accounts, which mostly benefit people in high income brackets;

• Reduce taxes on pharmaceutical, medical device and health insurance companies;

• Offer tax reductions totaling $274.6 billion over 10 years to the wealthiest 2 percent of Americans.

These and other provisions would take the nation in the wrong direction. Even with the ACA in place, 29 million remained uninsured in 2015; the ACHA would only push that number higher. And today, even many Americans with coverage face bankrupting medical bills for copayments, deductibles and uncovered services. By lowering the standards of private insurance plans and ending cost sharing subsidies, the ACHA would only intensify the problem of "underinsurance."

The ACHA would replace the ACA with a worse, more regressive version of the original bill. This is not what Americans want or need. PNHP instead urges Congress to replace the ACA with a single-payer national health care program. Unlike the ACA or the ACHA, single-payer, Medicare for All reform could effectively control costs while creating a right to high-quality healthcare for everyone in America.

anne -> anne... , March 09, 2017 at 02:25 PM
Clarifying:

http://www.pnhp.org/news/2017/march/pnhp-on-gops-re-branded-and-far-meaner-version-of-aca

March 8, 2017

The 'American Health Care Act' perpetuates the basic structure of the Affordable Care Act, including the subsidization of the private health insurance industry, while cutting benefits to the poor and middle class, and giving hundreds of billions in tax breaks to the rich
By Physicians for a National Health Program

libezkova -> anne... , March 09, 2017 at 05:37 PM
"• Sharply reduce the ACA's subsidies (or "tax credits") available to lower-income persons, particularly older adults, to purchase coverage;"

That's a shame. Over 50 and unemployed is hard enough for most Americans to be hit with additional health insurance charges.

[Mar 07, 2017] Republicans Look to Top 50 Million Uninsured

Mar 07, 2017 | economistsview.typepad.com
anne : March 07, 2017 at 11:10 AM , 2017 at 11:10 AM
http://cepr.net/blogs/beat-the-press/republicans-look-to-top-50-million-uninsured

March 7, 2017

Republicans Look to Top 50 Million Uninsured

In the years before the Affordable Care Act (ACA) the uninsured population peaked at just over 50 million people. It fell sharply when the main provisions of the ACA took effect, falling to less than 28 million in recent quarters. However, in its effort to make America great again, the Republicans expect to raise the number of uninsured back above 50 million. Serious analysis of their plan shows that they have a good shot at meeting this goal.

While the Republicans are in principle keeping some of the provisions of the ACA that were responsible for lowering the number of uninsured, this effect will be temporary. In most cases the situation for most people not covered by their employers will be the same or worse than before the ACA took effect.

For example, the plan leaves in place the expansion of Medicaid through 2020. This should be long enough so that most currently serving Republican governors will not have to deal with the effect of the elimination of this provision. After 2020 people benefiting from the expansion will be allowed to remain on Medicaid, but new people will not be added. Since people tend to shift on and off Medicaid (something rarely understood by reporters who cover the ACA), after two or three years the vast majority of the people who benefited from the expansion will no longer be getting Medicaid. By 2025 the impact of the expansion on the number of the uninsured will be trivial.

The plan also allows insurers to charge people with pre-existing conditions higher rates, if they allow their insurance to lapse. While the provision allowing people to avoid being penalized for pre-existing conditions, if they maintain continuous coverage, may appear to provide protection, in reality this is not likely to be the case. Before the ACA workers were allowed to keep employer based coverage for a substantial period of time after they left their employer under COBRA. * The take up rate under this law was always low, primarily because most workers could not afford to keep their coverage once they left their jobs. This is likely to be the case when the Republican plan takes effect as well.

The Republican plan does provide modest subsidies to people for buying insurance, but the impact of these subsidies will be swamped by the rise in health care costs. The subsidies would be $2000 a year for those under 30 and $4,000 a year for those over age 60. According to the Center for Medicare and Medicaid Services the average cost of health care per person was $9,100 in 2013. Per person costs are projected to rise to $15,800 by 2025.

The Republicans will be further helped in their plans to raise the uninsured population back above 50 million with their proposals for segmenting the market by encouraging healthy people to buy low cost catastrophic health care plans. The Republicans propose to raise caps on health savings accounts, which will give healthy people a strong incentive to buy plans with very high deductibles. As a result, plans that have lower deductibles will have a less healthy population and therefore be very expensive. This should make it more difficult for people with health conditions to afford insurance.

On net, it seems likely the Republican proposal will succeed in raising the number of uninsured above the pre-ACA level. Since this seems the likely outcome, it is reasonable to assume that it is the intention of the Republican designers of the bill.

* https://en.wikipedia.org/wiki/Consolidated_Omnibus_Budget_Reconciliation_Act_of_1985

-- Dean Baker

[Mar 07, 2017] The Republican plan appears to be a poorly considered rush job, not unlike the original ACA. It solves none of the problems created by the ACA and creates new problems of its own

Notable quotes:
"... The point is that 65-70% of the people want a single-payer. It is time to start making that into an electoral reality, and the way to do that is to start beating that drum now. The free market will never work for universal healthcare. God knows whether the Democrats have enough political brains to follow Bernie on this, however. ..."
Mar 07, 2017 | economistsview.typepad.com
mrrunangun : March 07, 2017 at 06:26 PM

, 2017 at 06:26 PM
The Republican plan appears to be a poorly considered rush job, not unlike the original ACA. It solves none of the problems created by the ACA and creates new problems of its own. Perhaps there are enough sensible people left in the Congress to do away with this nonsense, but I doubt that there are enough people there with a sufficient sense of public purpose to work together to improve on the precarious existing system resulting from the ACA.
libezkova -> mrrunangun... , March 07, 2017 at 07:58 PM
A very good insight ! Thank you !
Sporkfed : , March 07, 2017 at 04:36 PM
Increasing the demand for healthcare by providing insurance through a third party will
not contain healthcare costs, nor in the long run, provide quality, affordable, healthcare for the majority of the intended recipients. The monopolies that exist in American medicine must be
eliminated to reduce costs, all other "tweaks" are just bandaids. Single payer may be the best
solution to an intractable problem.
sanjait : , March 07, 2017 at 12:48 PM
Dems need to stand firm and be clear on their messaging, and they will win this debate and stop the GOP from passing a bill.

The GOP bill slashes Medicaid and the support that working families get for exchange insurance, all to finance big tax cuts for the rich. Those are the main things it accomplishes, and Americans are rapidly becoming aware of this reality.

Fred C. Dobbs : , March 07, 2017 at 12:12 PM
The polarization in the US is
such that while Dems & progressives
have accepted that 'universal
healthcare' is a basic right,
GOPsters & conservatives take
the other side. Except when they
too have become enlightened,
partially & somewhat, it seems.

House Republicans Unveil Plan to Replace Health Law https://nyti.ms/2myipXZ

... On Monday, four Republican senators - Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska - signed a letter saying a House draft that they had reviewed did not adequately protect people in states like theirs that have expanded Medicaid under the Affordable Care Act.

Three conservative Republicans in the Senate - Mike Lee of Utah, Rand Paul of Kentucky and Ted Cruz of Texas - had already expressed reservations about the House's approach. ...

See also:

4 GOP senators demand to keep Obamacare
Medicaid expansion http://politi.co/2lVflBP

Four Republican senators from states that expanded Medicaid under Obamacare say they can't support a draft House repeal bill because it won't protect people enrolled in the health entitlement - a move that could doom the legislation's prospects.

"We are concerned that any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services," Sens. Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska wrote in a letter to Majority Leader Mitch McConnell. "The February 10th draft proposal from the House does not meet the test of stability for individuals currently enrolled in the program and we will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states." ...

Lee A. Arnold -> sanjait... , March 07, 2017 at 01:26 PM
Sanjait: "Going 'single payer' in response is like throwing a Hail Mary pass"

Wrong analogy really, because a single-payer isn't legislatively possible at this moment. Kevin Drum has this right, as almost always. Beyond that, the GOP will never go for a single-payer; this is NOT the point. The point is that 65-70% of the people want a single-payer. It is time to start making that into an electoral reality, and the way to do that is to start beating that drum now. The free market will never work for universal healthcare. God knows whether the Democrats have enough political brains to follow Bernie on this, however.

[Feb 26, 2017] Clowbacks to benefits manager is "It's like crack cocaine," said Susan Hayes, a consultant with Pharmacy Outcomes Specialists in Lake Zurich, Illinois. "They just can't get

Feb 26, 2017 | economistsview.typepad.com
im1dc : February 24, 2017 at 05:26 PM , 2017 at 05:26 PM
Real World Economics

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

https://www.bloomberg.com/news/articles/2017-02-24/sworn-to-secrecy-drugstores-stay-silent-as-customers-overpay

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

by Jared S Hopkins...February 24, 2017...9:52 AM EST

> Gag clauses stop pharmacists from pointing out a cheaper way

> Cigna, UnitedHealth and Humana face at least 16 lawsuits

"Eric Pusey has to bite his tongue when customers at his pharmacy cough up co-payments far higher than the cost of their low-cost generic drugs, thinking their insurance is getting them a good deal.

Pusey's contracts with drug-benefit managers at his Medicap Pharmacy in Olyphant, Pennsylvania, bar him from volunteering the fact that for many cheap, generic medicines, co-pays sometimes are more expensive than if patients simply pay out of pocket and bypass insurance. The extra money -- what the industry calls a clawback -- ends up with the benefit companies. Pusey tells customers only if they ask.

"Some of them get fired up," he said. "Some of them get angry at the whole system. Some of them don't even believe that what we're telling them is accurate."

Graphic

Clawbacks, which can be as little as $2 a prescription or as much as $30, may boost profits by hundreds of millions for benefit managers and have prompted at least 16 lawsuits since October. The legal cases as well dozens of receipts obtained by Bloomberg and interviews with more than a dozen pharmacists and industry consultants show the growing importance of the clawbacks.

"It's like crack cocaine," said Susan Hayes, a consultant with Pharmacy Outcomes Specialists in Lake Zurich, Illinois. "They just can't get enough."

The cases arrive at a critical juncture in the quarter-century debate over how to make health care more affordable in America. President Donald Trump is promising to lower drug costs, saying the government should get better prices and the pharmaceutical industry is "getting away with murder." The Pharmaceutical Care Management Association, a benefits-manager trade group, says it expects greater scrutiny over its role in the price of medicine and wants to make its case "vocally and effectively."
Racketeering Accusations

Suits have been filed against insurers UnitedHealth Group Inc., which owns manager OptumRx; Cigna Corp., which contracts with that manager; and Humana Inc., which runs its own. Among the accusations are defrauding patients through racketeering, breach of contract and violating insurance laws.

"Pharmacies should always charge our members the lowest amount outlined under their plan when filling prescriptions," UnitedHealthcare spokesman Matthew Wiggin said in a statement. "We believe these lawsuits are without merit and will vigorously defend ourselves."

Mark Mathis, a Humana spokesman, declined to comment. Matt Asensio, a Cigna spokesman, said the company doesn't comment on litigation.

"Patients should not have to pay more than a network drugstore's submitted charges to the health plan," Charles Cote, a spokesman for the Pharmaceutical Care Management Association, said in a statement.

Read more: Escalating U.S. drug prices -- a QuickTake explainer

Benefit managers are obscure but influential middlemen. They process prescriptions for insurers and large employers that back their own plans, determine which drugs are covered and negotiate with manufacturers on one end and pharmacies on the other. They have said their work keeps prices low, in part by pitting rival drugmakers against one other to get better deals.

The clawbacks work like this: A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager "claws back" the remainder. Most patients never realize there's a cheaper cash price.

"There's this whole industry that most people don't know about," said Connecticut lawyer Craig Raabe, who represents people accusing the companies of defrauding them. "The customers see that they go in, they are paying a $10 co-pay for amoxicillin, having no idea that the PBM and the pharmacy have agreed that the actual cost is less than a dollar, and they're still paying the $10 co-pay."

On Feb. 10, a customer at an Ohio pharmacy paid a $15 co-pay for 15 milligrams of generic stomach medicine pantoprazole that the pharmacist bought for $2.05, according to receipts obtained by Bloomberg. The pharmacist was repaid $7.22, giving him a profit of $5.17. The remaining $7.78 went back to the benefits manager.
Opaque Market

Clawbacks are possible because benefit managers take advantage of an opaque market, said Hayes, the Illinois consultant. Only they know who pays what.

In interviews, some pharmacists estimate clawbacks happen in 10 percent of their transactions. A survey by the more than 22,000-member National Community Pharmacists Association found 83 percent of 640 independent pharmacists had at least 10 a month.

"I've got three drugstores, so I see a lot of it," David Spence, a Houston pharmacist, said in an interview. "We look at it as theft -- another way for the PBMs to steal."

Lawsuits began in October in multiple states, and some have since been consolidated. Most cite an investigation by New Orleans television station Fox 8, which featured interviews with Louisiana pharmacists whose faces and voices were obscured.
Tight Restrictions

Many plans require pharmacies to collect payment when prescriptions are filled and prohibit them from waiving or reducing the amount. They can't even tell their customers about the clawbacks, according to the suits. Contracts obtained by Bloomberg prohibit pharmacists from publicly criticizing benefit managers or suggesting customers obtain the medication cheaper by paying out of pocket.

Pharmacists who contract with OptumRx in 2017 could be terminated for "actions detrimental to the provider network," doing anything that "disparages" it or trying to "steer" customers to other coverage or discounted plans, according to an agreement obtained by Bloomberg.

"They're usually take-it-or-leave-it contracts," said Mel Brodsky, who just retired as chief executive officer of Pennsylvania's Keystone Pharmacy Purchasing Alliance, which buys drugs on behalf of independent pharmacies.

OptumRx is among the three largest benefit managers that combine to process 80 percent of the prescriptions in the U.S. The other two, Express Scripts Holding Co. and CVS Caremark, haven't been accused of clawbacks. CVS doesn't use them, it said in a statement. Express Scripts is so opposed that it explains the practice on its website and promises customers will pay the lowest price available.
Potential Death Blow

Pharmacies fear getting removed from reimbursement networks, a potential death blow in smaller communities. But some pharmacists jump at opportunities to inform customers who question their co-pay amounts.

"Most don't understand," said Spence, who owns two pharmacies in Houston. "If their co-pay is high, then they care."

States are responding. Last year, Louisiana began allowing pharmacists to tell customers how to get the cheapest price for drugs, trumping contract gag clauses. In 2015, Arkansas prohibited benefit managers and pharmacies from charging customers more than the pharmacy will be paid.

"The consumers don't know what's going on," said Steve Nelson, a pharmacist in Okeechobee, Florida. "We try to educate them with regards to what goes into a prescription, OK? You've got to kind of tip-toe around things."

ilsm -> im1dc... , February 24, 2017 at 07:08 PM
pharma to USG

like drug cartel in Mexico

except no briefcases

im1dc -> ilsm... , February 24, 2017 at 07:47 PM
That's a valid observation.

[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

View all posts by Lambert Strether →

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."
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"...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."
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"...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."
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"... 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 insu