Ian Welsh

The horizon is not so far as we can see, but as far as we can imagine

Tag: Obamacare

The ACA (Obamacare) Has Performed As Predicted

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On November 8, 2021

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So, Tony linked to a the abstract of a study of ACA cost:

As a measure of affordability, we calculated potential Marketplace premiums as a percentage of family income among families with incomes of 401–600 percent of poverty. In 2015 half of this middle-class population would have paid at least 7.7 percent of their income for the lowest-cost bronze plan; in 2019 they would have paid at least 11.3 percent of their income. By 2019 half of the near-elderly ages 55–64 would have paid at least 18.9 percent of their income for the lowest-cost bronze plan in their area.

Back in 2009 I wrote:

My current belief is that what will be passed will mandate everyone buy insurance but because of inadequate cost controls and subsidies will leave ordinary people forced to buy insurance which will increase in price faster than wages.

I also wrote:

..get ready to pay out for insurance you can’t afford, with co-pays so high you can’t afford to use it even after you’ve been forced to cough up for it.

This only half a “I told you so” because it was obvious. Anyone who didn’t know, who was paying attention, was an idiot, but most of those who said otherwise were liars.

Obamacare was always intended primarily as an insurance company bailout. The expectation was always that it would look OK for a few years, then prices would spiral.

There are a few ways to do healthcare that make sense, they all involve universal healthcare. The simplest is single payer. Cleaning up US healthcare requires more than that, since there are a lot of bad actors using oligopoly power to jack prices up artificially, but a single payer can force-set prices and drive companies out of business who won’t play.

The majority of Americans want universal health care, it’s not at all contentious. The reason Americans don’t have it is that part of the rich don’t want it, because it makes some of them wealthy, and they can afford to pay the inflated prices, so it isn’t a personal problem to them.

What the majority of Americans want is irrelevant, and as the Princeton study found, has zero impact on whether anything becomes government policy. This is as true when Democrats are in charge as when Republicans are.

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That Tax Cut Talking Point

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On June 24, 2017

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(MANDOS POST – YOU KNOW THE DRILL)

The Republicans are working hard to pass an amendment to the ACA called the AHCA. Assuming it succeeds, which I wouldn’t take for granted, it would take Obamacare, with all the latter’s deficiencies and faults, and make it even worse. Meaning: It will probably kill a lot of people through health care denial due to pre-existing condition denials and the reinstatement of lifetime coverage limits. If they fail to pass it, it would be because Obamacare is designed to make itself hard to retract; as Obamacare contains the bare minimum required to improve the status quo ante, anything significant they take away from it renders it unworkable. If it passes, it would be because they had decided that it was the closest to the status quo ante that they could achieve.

The status quo ante was terrible, but contrary to the beliefs of many, it wasn’t “unsustainable” in some sort of fundamental way. It could be contained by gradually excluding more and more people from insurance coverage, and therefore, down the line, care. This is not a debate about health care, but about how to pay for health care.  It is about austerity, and the status quo ante was ultimately just a slow ratcheting-up of austerity. (Yes, I know, Obamacare is a ratcheting-up of austerity, but it is a slower one.)

One of the talking points against the AHCA is that it appears to be designed to give the rich a tax cut. However, the tax cut is, in proportion to many of its beneficiaries, quite small, even as it dwarfs the incomes of many. It’s not a giveaway that in itself should raise the political passions of its beneficiaries. Many of them won’t spend it or won’t notice the effect on their lives or wealth planning. Even the insurance industry is skeptical of key portions of the bill, and they’re not prone, as they say, to altruism.

The Republicans have invested a lot of political capital in the idea of undoing Obamacare. Instead of that small a tax cut, if they were rational political actors, they could easily have come up with a bill that targeted large swathes of their constituencies for a substantial improvement in their (bad) standard of coverage, even if they wanted to target Democratic constituencies for tribal reasons. They could have done this without even instituting single payer (aka public monopsony) and ruining their constituents among the insurance and corporate medical sector. It doesn’t appear that this is on order.

The picture only makes full political sense if you see the cutting of health insurance coverage as a political goal in itself, if not some kind of fundamental ideological “end.” Or for the symbolic appearance of trading coverage for a token tax cut, in a way that is likely to create further damage to the US economy. And that successful Republican politicians think that they can expel millions of people from the ability to pay for health care, including their own constituents, is a sign both of the significance of that symbolic appearance and the cultural limits of the US health insurance debate.

The GOP Healthcare Plan

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On March 7, 2017

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This is a good overview.

I’m not going to waste a lot of time on it. Other than the changes to state-based regulations, the removal of the individual mandate and the removal of the tax on good healthcare plans (so-called gold-plated plans), as it stands, this plan is slightly worse than Obamacare in pretty much every way.

It is not an improvement, it is not what Trump promised in his speeches, though it’s not far from what was in his policy documents. It is also not a disaster, but it certainly won’t be a win for Trump or make his followers feel better off and it was one of two ways he could, or can, do so. The other would be to improve their economy.

This matters far more to Trump’s future, and his presidency, than all the noise over immigration or Russia. He should have pushed hard for something simple that was an obvious win; something Democrats would find it hard to oppose.

This is not a win for his supporters, or for him.

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The Public Option for Obamacare Was Not Impossible

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On January 9, 2017

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***This is a Guest Post by Dan From T.O.***

Back in 2009-2010, Chris Bowers, co-founder of openleft.com, (at the time an “A-List” liberal/progressive blog by all accounts*) and Adam Green of the PCCC led a set of outsider “whip count” exercises in support of improving & passing the Affordable Care Act.

  1. The initial whip count effort in 2009 was focused on garnering 60 votes for cloture in the Senate in support of a public option (the House bill had one). This actually succeeded,** and had all 60 Democratic senators on the record in support of a public option, until 4 Senators backed out.
  1. In early 2010, a whip count was run to gain Senate support to pass health care under reconciliation rules (meaning only 51 votes were needed for passage). This also succeeded, and ultimately the ACA included a “side-car” reconciliation fix once Democrats lost the 60th vote in the Senate via the MA Senate special election.
  1. Concurrently with #2, another whip count was run to pass a public option via reconciliation. This also succeeded and Bowers & Co had 50 or 51 Senators publicly in favour of passing a public option through reconciliation.

All this is to say: The Public Option was very plausible. Even Joe Lieberman & Ben Nelson were open to it and, really, they weren’t needed as it could have been done under reconciliation. Is it 100 percent certain that it could have passed? Of course, no counterfactual can be perfectly certain. Given how close Bowers et al. got without much support from the Democratic leadership, and in fact the secret opposition of Obama who had traded away the Public Option, it is not ascribing magical powers to the Bully Pulpit to think that if Obama had wanted a Public Option in the bill, he could have got one.

The history here in this set of posts by Bowers is worth a review of the chicanery in play. In both occasions, progressive activists were given seemingly impossible tasks to get a public option passed, did so, and somehow had the goal posts moved. The posts read like a House of Cards plot to manipulate activists; not giving them what they wanted while still appearing sympathetic. For instance, this excerpt from Bowers’ 2009 post-mortem:

Back on May 21st, there were only 28 Senators in support of a triggerless public option. Through your tireless participation in a whip count effort, by October 8th we raised that number to 51 when Jon Tester came out in support. By October 30th, when Evan Bayh said he wouldn’t filibuster, we were up to 56 Democrats for cloture on health care reform with a public option.

From that point, the only four Senators we still needed all lied to us in one form or another.  Both Mary Landrieu and Blanche Lincoln signed a document stating that they supported a public option, only to reverse their positions.  Blanche Lincoln’s website still comically claimed she supported a public option even as she was declaring her opposition to one on the Senate floor.

Still, Landrieu, Lincoln and Ben Nelson were all part of the group of ten Senators who forged a deal on the public option that included a Medicare buy-in.  Further, immediately after that deal was reached, Harry Reid contacted Joe Lieberman to see if he liked the deal.  Lieberman told Harry Reid that he was liking what he was seeing, and just wanted to wait for the CBO report.  Further, Lieberman had supported an even stronger Medicare buy-in (for Americans aged 50-64) as recently as September 2009.

Six days later, Lieberman and Nelson went on national television to engage in some more mendacity. Lieberman said he would filibuster the deal, despite the facts that he’d told Reid he liked it and had recently advocated for it. Ben Nelson badmouthed the deal even though he helped forge it.

Tell me that does not read like Obama’s team working behind the scenes to flip Lieberman & Co. back to ensure the deal with Pharma was kept.

The demise of the Public Option in the 2010 effort comes off about as bad, with a bad-faith exercise in finger pointing between the House & Senate over who should add the Public Option to the bill, and even a bonus arm-twisting of Bernie Sanders to try to prevent him from doing so by amendment.

All of this is “I told you so” of course, but I-told-you-so is important at times so mistakes aren’t repeated. The ACA is most likely going to be gutted or repealed entirely and the lack of a Public Option has certainly not helped it ever get the strong base of public support it needed to survive a term of opposition government. If one reviews the history of polling on the ACA, it is clear that between the “it’s ok” camp and the “it needs to be expanded/made more liberal” camps there is consistently well over 50 percent support for it, but in straight up approval polling, the law was always more unpopular than popular.

The theory from the law’s proponents back in 2009-10 was that once it took effect and started helping people, it would get more popular. This was plausible except that it isn’t really what happened–probably because private insurance companies are awful to deal with. Thus, more people felt the ACA was hurting rather than them as time went on:

The public option would have meant that those people finding they hated the exchanges could have opted out of that mess and bought into some version of government provided plan that could have been simple, not subject to major price changes, and regular cancellations (frequently a problem for ACA plans). It also would have meant more people attributing their shiny new access to health care to Obama and the Democrats which only could have helped in those mid-term blowouts.

Like his unforced errors on the too-small stimulus, HAMP helping banks instead of people and not prosecuting Wall Street fraud, this error is on Obama: He chose to not have a public option in the ACA and if he’d wanted one, it is quite likely he could have had it.

* – See here for Hillary Clinton herself being sent an openleft.com post from 2010 per the Podesta email dumps.

** – Sorry, link rot has really set in on a lot of this. Someone (Bowers himself possibly) is maintaining the archive of openleft.com posts I am linking to but most of the links from those posts no longer work.

Obamacare Failures Are by Design

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On November 15, 2015

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Look, this is not a mistake by Obama. This is how Obamacare was designed:

for many consumers, the sticker shock is coming not on the front end, when they purchase the plans, but on the back end when they get sick: sky-high deductibles that are leaving some newly insured feeling nearly as vulnerable as they were before they had coverage.

“The deductible, $3,000 a year, makes it impossible to actually go to the doctor,” said David R. Reines, 60, of Jefferson Township, N.J., a former hardware salesman with chronic knee pain. “We have insurance, but can’t afford to use it.”

Obamacare was a way of bailing out insurance companies and for providing catastrophic insurance coverage, which is meant to protect hospitals. If someone requires many thousands of dollars of care in one go, the hospital doesn’t have to eat it.

Meanwhile the high deductible, plus the relatively low percentage of premiums which the plan should be designed to pay out, are intended to keep insurance companies in business, as they were becoming less and less profitable.

In-network vs. out-of-network rules and deductibles also make the insurance hard to use in many parts of the country, and, again, this was by design.

Obamacare was never designed to make sure everyone had health care, it was designed to help insurance companies and hospitals—to get money to  people who matter.

I strongly suspect it was also intended to preempt the logical plan of simply extending Medicare to everyone. Obama went out of his way to make sure there would be no public option, as well, trading it away right at the beginning.

Obamacare is a corporate subsidy. Some ordinary people get helped, but that is a side-effect.

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