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

The Obamacare Fiasco

I think Schadenfraude nicely sums up what I’m feeling about Obama’s troubles with his signature health care bill, though I do feel  sorry for people who are being hurt by Obamacare.

It’s not the website that is killing Obama, of course, it’s the cancellation of pre-existing policies (though the website is an unforced mistake).  Obama told people they could keep their policies, but that decision was never his to make, it was up to insurance companies.  Since there is no robust public option, Obama does not have any significant leverage over the insurance companies, there is nothing he can do to them, so why shouldn’t they do what is in their best interest?

Please don’t say something like “because that would hurt people” because I’d laugh so hard I might rupture something.  Insurance companies are run by evil people as a class, and they make their money, not by providing care but by denying it.  The more care they deny, the more money they make.  One of my friends once designed medical “interest free” loans for people who needed life-saving operations.  Sounds like a deal, doesn’t it?  Of course, that’s zero interest on list price, not on what the insurance company was paying.  The company was making a hundred to two hundred percent profit per policy. Nice business to be in, if you have no soul.

When you are dealing with bad people, you must assume bad faith; bad behavior.  You must plan for it.  The best option was always Medicare-for-all (and I was told by at least one House staffer that they could pass it if they really wanted to and were willing to go nuclear.)  The problem with Obama has always been this sickening need to be one of the boys.  He appears to genuinely like and genuinely admire the people who have “made it” in this society—people like Jamie Dimon and the people who run insurance  and drug companies.  He thinks you can make deals with these people, and make sure everyone wins.

You can’t.  These people are the most successful parasites ever produced by our nasty form of sociopathic capitalism.  You can only give them what they want or you can rip them from the body politic, so they stop sucking the blood from the host they’re killing.

So the insurance companies have bitten the hand that fed them.  Obama gave them everything they wanted and made sure nothing of importance they didn’t want (like a public option) was in the bill. Now they’re chomping and chewing, destroying what remains of his presidency.

He has reaped as he sowed.

This is going to get worse.  As Corrente has repeatedly pointed out, the provider networks on the low cost plans are extremely thin.  People are going to find out that they’re only covered in theory, that there is no hospital that treats their type of cancer anywhere near them, for example.  They’re going to find out that they’re paying for coverage they cannot, in effect, use, for any number of reasons.  Drug costs will continue to rise, as well, since Obama carefully made sure all methods of reducing them were made illegal.

Obamacare was, and is, a subsidy.  A way of keeping the insurance companies going; of keeping the current healthcare system going.  The good, gold-plated private insurance plans, unless you’re an executive, are pretty much gone. As such everyone had to be forced to buy a shitty private insurance plan.  It will definitely help some people, some people will win, but many people will lose.

I will point out, for what feels like the millionth time, that simply putting everyone on Medicare would have been less expensive per person and produced better outcomes.  Even a robust public option would have given Obama leverage, because the insurance companies would have been scared everyone would migrate over to it, and so would have needed to treat people well.

But this… this is the worst of all worlds, and that is how it was designed to be.

It’s unclear to me how much of this is corruption (rest assured, Obama, like Clinton, will make tens of millions miraculously quickly on leaving office) and how much is some pathological need to be one of the boys, but I am clear that this failure is the inevitable product of how Obamacare was designed.


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  1. This bill was the result of the voters’ unwillingness to sacrifice anything to achieve “health care reform” Legislators were swamped with demands from people who had health insurance and were not willing to give it up. Some 85% of the voters in this country had employer provided health insurance, and they emphatically did not want “Medicare for all” to take over. Those who were on Medicare deluged legislators with demands that Medicare not be changed. Voters of every description howled with outrage at the idea that taxes might be raised or the deficit increased. Insurance companies, medical providers and pharma was adamant that their profits could not take a hit.

    Legislators were pragmatic; reelection demanded that they meet the criteria. Those with insurance could keep it, employer-provided insurance would be kept, Medicare unchanged, reform would be done at no cost, and corporate profits protected. The result stinks, but that’s what you get at the “free lunch” counter.

  2. zot23

    One small adjustment Ian: Medicare for all wasn’t just the best option then, it is also the best today. Whether we wish to fight that battle or not, let’s admit we could pass it today if we were truly committed to doing so.

  3. proofreader

    their at end of paragraph 5 s/b they’re.

  4. bystander

    Yes. To everything you’ve written. And, it’s criminal to it’s core because it did not have to be this way. My first measure of Obama was when he did a turncoat on holding the telecoms accountable for surveillance. I gave up when the behind the scenes assurances Obama was negotiating ultimately killed the public option at the same time the town halls to explain it were occurring. There was no reason to support his pretty-words initiatives after that, and little reason to be shocked at anything that has transpired from his administration since then. It’s all been dismally, predictably, downhill from there.

    As for:

    It’s unclear to me how much of this is corruption … and how much is some pathological need to be one of the boys…

    This could be a question about Obama’s policies with regard to finance, immigration, social security, or any other White House undertaking. The answer doesn’t matter very much if the outcome is effectively the same. Regardless of motivation, Obama is inflicting a whole lot of pain on the majority of American citizens.

  5. though I do feel sorry for people who are being hurt by Obamacare

    Well, at least there’s that.

    The American medical system is a mess top to bottom, and it kills people, around a hundred thousand a year I seem to recall, due to what they euphemistically call “medical error.” That’s on top of the 40,000 or so who die because they can’t get care due to lack of insurance or inability to pay.

    That’s before the tender mercies of Obamacare. Imagine what it will be like once this contraption is fully operational, assuming it ever is.

    The Rs have been ritually accused of sabotage of the Grand New Health Care Deal, but the problems go well beyond bad mouthing and nay-saying. Of course the soul-less ones in the insurance cartel boardrooms and hospital administrative suites are going to squeeze this teat for all its worth and then some. It is what they do, an identity thing with them and their ilk.

    If there has been sabotage it’s come from those who want a bigger slice of this huge new pie. It’s come from the corps of contractors who put together the wheezy website, it’s come from the insurance cartel and medical suppliers, it’s come from private sector health care bureaucrats and administrators.

    The Rs are taking full political advantage of the situation but mostly for sport. They have never had any intention of stopping Obamacare, they simply want to hang the albatross around his neck. But it seems to me, Obama has been more than capable of placing the bird’s carcass around his own neck.

    His motives don’t matter much to me. The issue is that this monstrosity is not only hurting people (“only a few! only a few! settle down!” — I loathe the propagandists attempting to make light of the problems or to blame the victims) but it is terrifying many, many more.

    Talk about “uncertainty.” (Nobody knows when their premiums will skyrocket or their policies will get cancelled; nobody knows when the website will work. Few can figure out how to navigate the incredibly confusing and complex exchange system. Fewer can truly afford the shocking costs of having and actually using almost any sort of “coverage.”)

    And it will only get worse as the feeding frenzy continues unabated.

  6. What’s sickening is the Obots’ desperate need to believe that the Obama Presidency has changed anything for the better, when it hasn’t. You’d think that hanging out with all those freethinkers would have made the Obots free to think. It hasn’t.

  7. bystander

    And, the push-back to even the smallest “fix” begins…

    What’s the over and under to how long it takes Obama to buckle?

  8. Jerome Armstrong

    Ah, the unintended consequences of massive governmental-corporate collusion again. Quite the conundrum.

    Yea, 6-9% getting a cancellation now. How many more percent getting a cancellation from their employers when the employee mandate kicks in next year?

    No young healthy single in their right mind would sign up for this rentier crap. What a bait and switch on the young votes Obama pulled off. Certainly a Nixon to China moment on behalf of the corporations by the Democrats.

    I don’t want to spend too much time thinking about it though, because if I can imagine how it could get more f’d up, it probably will.

  9. Jerome Armstrong

    @bystander, I will give say we are a week away, next Thursday or Friday, for that event. Probably just some sort of re-wording of the bill at a minimum.

    What’s amazing here is that the Republicans are so ham-handed that they think they should stop attempts to make a fix to the bill because they believe they’ve a political advantage. When will they ever learn that the public isn’t going to trust them until they actually believe in helping people.

    The whole situation– a f’d up government, a f’d up website, no ability to work together by the parties. The waters need to rise and pull them out to sea.

  10. alyosha

    …The problem with Obama has always been this sickening need to be one of the boys. He appears to genuinely like and genuinely admire the people who have “made it” in this society—people like Jamie Dimon and the people who run insurance and drug companies. He thinks you can make deals with these people, and make sure everyone wins.

    I think you’ve nailed it. Another writer put it more compactly if less clearly: “He’s a putz”. All that intelligence, education and oratory, for what?

    FWIW, My moment of clarity happened in March 2009, when I heard him addressing a crowd about banking reforms. Don’t remember the exact content, but I knew 1) he didn’t have a clue about the real problems in our banking system, or 2) he’s just plain lying. Going along to get along, and trying to take the country down with him.

  11. Not parasites, predators.

  12. S Brennan

    Lambert is comparing O’bomberCare to HAMP and he’s got a good chart to make his case.

    But my disaster analogy would be the AF-PAK, where the US went from Bush’s 18,000 troops, to 135,000 under O’bomber. The press has ignored the AF-PAK story, but we are withdrawing under duress, having failed completely in our stated mission. I bring this up, because like O’bomber’s adoption of the Heritage Foundation’s health insurance welfare program [AKA ObomberCare], the AF-PAK escalation was done with the complete support of the O’Bomber nation. O’Bomber made clear he intended to be a “war president”, a smarter “war president”, but a “war president” nevertheless…and his fan club cheered him on.

    Which brings me to the point of the post, O’Bomber has been the more “effective evil”, because of the UNDYING love of his faithful followers.

    O’Bomber supporters own HAMP
    O’Bomber supporters own FISA.
    O’Bomber supporters own TARP.
    O’Bomber supporters own O’BomberCare
    O’Bomber supporters own the AF-PAK disaster.
    O’Bomber supporters own the “Stimulus” bill which was 65-70% Tax Cuts for the rich.
    O’Bomber supporters own the bombing of Libya, W/ Negro genocide performed by Al Qaeda.

    The blame for O’Bombers squalid years falls squarely on his fanatical supporters shoulders. O’BomberCare is the Presidents “Katrina” moment, where all but the true “believers” see O’Bomber for who he is and the “dead enders” are seen for who they are.

  13. cripes

    Yeah, the only thing that sickens me more than barry–that empty suit, mealy-mouthed subservient little turdblossom–is the legions of deluded, diversity-addled, cheerleading “team” players that support him “110%”. That’s a quote from an O’zombie. This is like the Eighteenth Brumaire of Napleon Bonaparte. A farce with a corrupt cast of fools at the helm. God, we need a cleansing rain.

  14. Jerome Armstrong

    Don’t forget that moment when we had the triple-morph of warmongering over Syria, when we heard Pelosi, Kerry, & Obama try to invade Syria with bombs, sounding no different than Bush, Cheney & Rumsfeld. Not even pre-emptive cover, just emptiness.

    And drones dropping and killing innocents globally. Plain evil. Owned by Obama. The only thing he can openly say he’s good at doing, and we have to agree.

  15. S Brennan

    Now you know why O’Bomber delayed implementation until after his 2nd & last election. I say he will rake in more than Clinton’s 100 million within 5 years of handing his successor the keys.

  16. So here’s the plan for global governance. Lie, and then when those who were cheated by your lies start to complain, go back on your lies. Your legions of adoring followers will never notice.

  17. Healthcare insurance is a “patch” on capitalism. It’s there to fix a gaping hole in capitalism: nobody in a capitalist society can afford healthcare without insurance. Nobody. Capitalism may deliver the most, the best, the cheapest, the greatest variety of widgets. But it doesn’t provide affordable healthcare to anyone, even the rich, without the patch.

    It is monumentally stupid to let capitalists operate the patch on capitalism. Letting capitalists run healthcare insurance is like letting foxes run the henhouse.

    There should be no such thing as “for profit” healthcare insurance companies: because there should be no profit in denying people needed healthcare; because healthcare is fundamentally unlike widgets.

    Bumper sticker: Medicare for all. Problem solved.

  18. Benedict@Large

    I know it’s all very populist to say that insurers make their money by screwing people out of money they’re due, but as a former member of your “evil people as a class”, I can assure you that’s never been the case, at least going back into the 1970s, when I started. The reality is that the insurance portion of the business is run as a break-even, while the entire profit is generated from cash flow. The cash flow is of course massive, and therefore, so are the profits.

    Zeese and Flowers say this same thing you do with a slight difference; they include charging as high as they can, with your paying as low as they can. Both of these are false. First, payments are specified in black and white in documents called contracts. We pay, or we end up in court. Second, if you want to maximize cash flow, you don’t do that by charging MORE than your competitors, you do it my charging less. Lower premiums = more contracts = maximum cash flow.

    So what are all these fights about over payments? Well, most of them are in the individual market where people don’t have the power to fight, but that’s only 10% of the market. 90% of the people who have non-government insurance are provided it via their employers, and employers do have the heft to sue. So we’re talking about very small segment of the marketplace here, and we’re getting down to anecdotal level, which is always made to sound worse than it is. But even here, people aren’t denied claims to make a profit, they’re denied claims because the product has been underpriced. (Remember, low prices = higher cash flows.) Frankly, the individual market priced itself out of existence years ago. It just hasn’t stopped selling policies yet. And that’s what you get: Lower the prices enough that people will still buy the product, and then screw the high cost people so the low cost ones can still be covered, and you can still make your margins, which remember, are break-even. Cash flow is everything.

    Anyways, that’s how it works. It’s not a bunch of evil people. It’s just a product that’s gotten too expensive that people can’t live without. What do you expect the insurers to do. Look at their stockholders one day and say, just to be nice, we’re going out of business. Sorry about all the money you had invested with us? Sorry, but it doesn’t work that way, in insurance or in any other business.

  19. Benedict@Large

    Just to be clear, I’m no lover of insurance in medicine. Within 5 years of beginning in insurance (1978, to be exact), I could see the writing on the wall. That medical inflation was and would continue to eat away at the viability of medical insurance, until it was no more. 1978, I began to advocate single-payer, just show up for care. It’s the only thing that works. The only thing that can work.

    But I do know how the business works from the inside, and that’s what I was describing above.

  20. Ian Welsh

    I’ve worked in the business as well, strangely enough, though on the Life side, but I have knowledge of the medical side. What you advocate for, if you’re an honest executive, is something like what the Swiss or Germans do, which is very fixed policies, with fixed profit rates, and fixed everything else (very few real options, but genuinely good insurance), but done through the private sector. You keep your jobs, you siphon off your share, everyone gets covered.

    There are non evil ways to stay in business and not go single payer.

    That’s not what they chose to advocate for.

    I, of course, don’t expect someone working in medical insurance to admit it’s an evil business run by evil people, though some, like my friend who ran the shady side of your business, have done so. (You realize I could use almost the exact same argument you did above to cover for mercenary companies, arms manufacturers, fishing companies that use wall of death nets…?)

    The structure of our economy requires evil people to run the companies. If you aren’t willing to do evil, you don’t wind up as an executive. Oh sure, many of them don’t see themselves as evil, after all, if they didn’t do it, someone else would.

    Every evil enterprise in world history has run on that rationalization.

  21. VietnamVet

    This post is an excellent description of what’s happening with the Affordable Care Act.

    American Health Care System and the Department of Defense are crony capitalism in their full flower. The problem is that the plutocrats are rampaging; pillaging the peons. Money to spend by the masses is drying up. Boeing, the last global American manufacturer, is decimating its worker benefits including healthcare. Lockheed Martin is laying off workers while increasing profits.

    Ending atmospheric warming or providing Medicare for all, means ending Capitalism’s shortsightedness and the endemic corruption. There is no chance that the Fat Cats will let this happen voluntarily.

  22. John Puma

    Below is the outline of a healthcare insurance bill I wrote in March of 2010. I claimed then, as now, that it would have (had) full support and compliance of insurance companies and Republican governors & legislatures.


    Puma Plan to sweeten the Obamacare deal:

    1) It is a felony punishable by death to provide health care insurance to natural persons in America.

    2) Insurance companies, in existence at the passage of the bill will receive (on September 11 of each year) transfers, directly from the US Treasury, in the amount of 200% of the previous year’s sum, the first payment being based on their reported (pre tax, ha-ha) revenues for 2009.

    3)  Two years after the bills passage, a one-time, $100 billion payment will be made to the health insurance company which has cut the highest proportion of it’s pre-bill work force while still adhering to the provisions of this bill (i.e. depositing a fat, and ever growing, tax-payer provided check once a year, as #2, above).

    4)  All current health care insurance policies will be cancelled, effective immediately upon he signing of the bill.

    5)  Each person named under the now defunct policies will get one nickel for each time the press/congress has mentioned the possibility of including a public option via reconciliation in the last three months.  The CBO will provide the final figures but this sum is thought to be approximately $5.00 per person.

    6)  “Health care savings accounts” will be established so that persons recently stripped of insurance coverage can wisely invest the over-generous $5.00 windfall in the warmly-respected financial industry of Wall Street.

    7) Any request for abortion, regardless of intended method of payment, needs unanimous approval by a “life panel” composed of all current Taliban prisoners of the US military PLUS James Dobson, Pat Robertson, Tony Perkins (FRC) and the nastiest, meanest, most misogynist pig that can located among the neo-fascist “Dominionists.”

    8)  The moment the bill is signed a small bell will be quietly rung to formally signify the end of the American charade, errr, experiment that had alleged, but has now, conclusively, failed, to bring into fact the lofty words that the founders used to justify the existence of the USA.  (Where does “bottomless greed” appear in the constitution?)

    In order to insure bipartisan support for the above proposal, AND retention of corporate donations, each Democratic member of congress will sign a contract offering the lives of each of their family members, if 
    a) the Democrats retain their majority after the 2010 midterm elections, but 
    b) subsequently fail to completely criminalize health care insurance, itself, in the 112th Congress

    This should guarantee a truly “bipartisan reform” bill and, we can only hope, that then the corporate/congressional/tea-bagging harpies  will stop screeching so the rest of us can, at least, expire from our pre-exiting conditions in effin’ peace.

  23. S Brennan

    “We pay, or we end up in court. ” Bullshit pal, Bullshit. Non-Payment ends up in front of an insurance commissioner and since he’s a rotating insurance excec. This is what you get.

    …Burst appendix, yep it’s a preexisting condition that you’ve hidden for the 3 months since you had this new policy. yep next.

    ….But I’ve got letters from the surgeon, letters from my doctor? How am I gonna pay $26,000.00

    ….It’s clearly a preexisting condition…final answer

    …I am sorry to tell you this, you’ve got a good case, but while we can legally go after them, these cases are costly, fees alone run about 40% because they use the courts to delay as long as humanly possible, so with my cut of 30% , you are betting that you are awarded 3X damages and that does not happen like it used to, you could win and be further behind than you are now. My best advice, go to the charity section of the hospital and explain that insurance is calling this a pre-existing and ask what they can do for you.

    I did, I had to pay the Doctor in full, but he gave me the discount insurances demand. The Hospital agreed to an 80-20 split, with me paying the first $3,000.00. Total approximately $14,000…almost lost my house and I was very lucky the hospital worked with me.

    “We pay, or we end up in court. ” Fuck you and your lies. I never understood the crowds who gathered at the guillotines to cheer a man/woman being executed…I do now. Revolutions are generally bad things, but it’s clear from the lies spewing forth, blood needs to flow.

  24. Excellent, excellent post.

  25. seabe

    I don’t think and didn’t think Medicare for all would have done it tho, Ian. The problems have become so compounded that we need something far more radical. I think Governor Schweitzer’s experiments with state run health clinics with doctors on salary has a lot more potential. Or even federalizing Medicaid, removing the contractors, and expanding that to everyone.

    A lot on the left are upset at lower Medicare payments to doctors — though the cuts in Medicare came more from the Part D side of it –but the fact remains that prices remain too high, and they must come down. Primary doctors should probably be paid a bit more, but on salary. Then hit the hospitals and specialists hard.

    I supported the bill because of the Medicaid expansion. The other parts were irrelevant as the system cannot last much longer as it is; and failure to pass anything wouldn’t have made that reckoning happen sooner, just more denial and waiting another decade to try again.

  26. someofparts

    “When you are dealing with bad people, you must assume bad faith; bad behavior. You must plan for it. ”

    I’m finding that there are still many who struggle with that idea. It seems to take a measure of misfortune, especially over time, for people to begin to see that point.

  27. Au contraire, this is exactly what the system needed. Can’t easily go back to the old system, but the last-ditch attempt at making the for-profit insurance model work, doesn’t. You couldn’t have gone to single-payer directly, Lieberman told you why not, and why lowering the Medicare age or a public option would not be implemented then: the USA was not at the cultural moment when it was willing to abandon for-profit basic health insurance, and it was too obvious that those solutions would inevitably lead to that.

    Now we can have the actual test of how committed the American voter is to for-profit health-care. If they vote for abolition of Obamacare by voting massively Republican in the midterms, then we know that how much libertarian rhetoric has truly poisoned the body politic. If they vote for fixing it by providing a new solution outside the for-profit/employer-based/etc insurance system (be it single payer, etc), then so much the better.

    By the way, I partly blame libertarians for this. Fine, sure, NSA and wars and all that. But you can’t have libertarians and have single-payer at the same time. They’re oil and water.

  28. Yeah, the only thing that sickens me more than barry–that empty suit, mealy-mouthed subservient little turdblossom–is the legions of deluded, diversity-addled, cheerleading “team” players that support him “110%”.

    (My bold.) By the way, this is why y’all are failing here. If you’re not on the identity politics train, you’re not on the train, period.

  29. Greke Kekek Coax Ltd.

    Tomorrow on this blog we’ll bring in a doctor with a flashlight to show us where Mandos gets his assessments of what the “cultural moment” will allow.

  30. seabe

    In addition to what Mandos said, Medicare isn’t that great as it is. People still go bankrupt on it. We need to remove copays deductibles ala Medicaid. Medicare still would cost 450 a month in premiums with an 1800 combined part AB deductible. And then everything is 20% coinsurance. Truth be told, Medicare sucks only a little bit worse than the for profit racket. Its only real advantage is in admin costs.

  31. S Brennan

    While I rarely agree with Mandos, [he will surely verify], but I agree with his point:

    “the USA was not at the cultural moment”

    The “people” were not concerned about healthcare at all, people were concerned with the financial shenanigans and the bailout of the perps…domestic spying and ending Iraq*.

    O’Bomber’s supporters didn’t care that, he, of all the candidates, did not have a healthcare plan. O’Bomber supporters wanted to validate their self-admiration of their purity on matters concerning race…and hey, whats easier than pushing a chad to prove your noblesse oblige? Healthcare wasn’t a concern to O’Bomber fans, just look at the demographics.

    No, it was absolutely the worst moment.

    So why did O’Bomber do it? Well, remember back to that debate when he was an “empty vessel” on healthcare reform? Guess who filled his vessel? 20 million dollllars from the healthcare insurance industry that’s who. A black candidate that opposed O’Bomber in Illinois referred to him as a “corporate step’in fetch’it”, that guy was a jerk, but he had O’Bomber’s number.

    *At least superficially, after a [D] president was installed, it no longer mattered.

  32. Ian Welsh

    Polls at the time showed bare majority support for medicare for all and 70% support for a public option.

    The cultural moment stuff is incorrect, America’s elites were not in the cultural moment, perhaps.

  33. cripes

    Majorities have supported expanded Medicare, Social Security increases, raising the minimum wage to living wage, reducing warfare expenses, increased taxation of corporations and the plutocrat bandits, etc. and so forth, for decades.

    So, whatever “cultural moment” MSNBC and others keep saying makes the will of the people impossible to implement is just catapulting the propaganda, undermining democracy and the popular will, and is, basically, a load of horseshit. They may control the media, but lies are still lies.

  34. S Brennan

    The majority of Americans support all manner of good and decent things…but Pols have been listening to their contributors…and not the people for 35 years. At the time, there was a powerful wave to restore the financial controls of FDR and to put those involved in the fraud [say rating agencies for example in prison] and strengthen the safety net for Americans hurt by Wall Streets corruption.

    O’Bomber diverted that focused attention away from Wall Street [the headwaters of corruption] and like a pied piper march his followers into a roach motel of medical insurance welfare. He scored a twofer. Again his biggest contributors are Medical insurance, Financial & Pharma at 20, 17 & 13 million apiece. Viewed from these numbers, it’s pretty obvious what O’Bomber did.

    Again, none of what will become known as the most corrupt administration in 90 years would have been possible without his faithful followers. O’Bomber was a paid tool and he did what all corrupt pols do. What made O’Bomber powerful was the UNQUESTIONABLE FAITH of his followers. It is those quislings that are the rot of our society, even today they deny and obfuscate for their “dear leader” the “light giver”…pathetic.

  35. Insurance companies … make their money, not by providing care but by denying it. The more care they deny, the more money they make.

    That may have been true in the past Ian…, but now the ACA mandates that 85% of revenue has to be spent on services I believe. So…, read another way…, they are guaranteed a 15% profit margin…, and the only way they can make more money…, is to spend more money on services. Denying services would only lower the amount of that 15% profit margin. Get ready for massive premium increases to cover all those services that they will be more than willing to provide now to increase the amount of the 15% profit margin. I don’t see any incentive for the providers to hold down costs by denying service…, or trying to negotiate with doctors or hospitals for lower costs.

  36. David W Farrell

    I’m going to read your blog as long as you write it, and your analysis of the affordable care act seems likely to me, but that notion in the last paragraph is just wrong. The man’s worried about legacy not money, leader of the free world is on his mind not beach front property. Its not cash-its credit for successfully managing he seeks.

  37. Can someone explain what a public option would look like? i don’t get it. So you pay premiums to the government? Or you “buy” into Medicare like you do now? Governor Schweitzer’s attempt to get costs down by paying salaries to doctors like they do at Mayo’s and expand Medicaid makes more sense. No copays or deductibles. He has studied how they do it in Saskatchewan which has about the same population as Montana. I would imagine he will run for president on these ideas.

  38. Ian Welsh

    Wanting to get rich predicts Obama’s actions much better than wanting a great legacy, or he’d have done very different things with relation to the banks and economy.

  39. David Atkins

    I like that: when dealing with evil people, assume bad faith and plan for it.

    And Corrente.

  40. All you had to do was read this passage in “Audacity of Hope” published in 2006 to understand a lot about Obama.
    Talking about Reagan’s election

    …”I understood his appeal. It was the same appeal that the military bases back in Hawaii had always held for me as a young boy, with their tidy streets and well-oiled machinery, the crisp uniforms and crisper salutes.”

    Tidy, well-oiled, crisp, crisper…

    He respects Reagan for embodying “American’s longing for order.”

    So we got the cleaner, neater, crisper, more orderly version of the messy Clinton. Well, I, for one, like a little disorder. Marching in crisp and orderly lines with lots of well-oiled machinery is not my idea of fun. I do understand that a lot of people are more comfortable following orders and staying in line, but freedom will be sacrificed for that comfort.

    With the clue in the book and Ken Silberstein’s 2006 Harper’s “Barack Obama, Inc”, he should never have been the darling of the professional progressives. But he was. And so here we are.

  41. Quoth GKCL:

    Tomorrow on this blog we’ll bring in a doctor with a flashlight to show us where Mandos gets his assessments of what the “cultural moment” will allow.

    I don’t know about you, but I for one don’t look at election results with a flashlight.

    Quoth Ian:

    Polls at the time showed bare majority support for medicare for all and 70% support for a public option.

    The cultural moment stuff is incorrect, America’s elites were not in the cultural moment, perhaps.

    As I said at the time then, and as I’ll say now, it doesn’t matter what the polls show on particular policy issues. “Do you want a bag of chips?” That’s not how representative democracy works. It matters what people will do at the ballot box. What they will weight as their priorities and who they will elect based on that weighting, what options they will consider, and so on. Needless to say, non-voters don’t count.

    One of the most surreal moments of those bygone days was when PNHP held these weird citizens forums (I can’t find the link anymore…ah, here it is) where they were touting some kind of “citizen jury” where people would be educated into the right options or something like that as a better way to assess political consequences than the focus groups that the Herndon Alliance was holding. They were mocking the “goofy” categories that the focus groupies used to construct their analyses.

    What election campaign on Earth behaves like a “citizen jury”? If you want to look to what really drives voter psychology, look at Hallmark greeting cards and the schlocky sentimentalism there.

    So no, the cultural moment wasn’t there. Many Americans might say they want Medicare for All (or however you title it), but many will balk when it is expressed that they have to give up *their* plan or pay for *those* people, and libertarian populism *works* well enough to tip the balance in the system. People who thought the USA was popularly prepared for single payer were wrong then, and they might even be wrong now, but *possibly* less so, after we see how the Obamacare fiasco(es) work its way through.

    (I lived the American health insurance experience after decades under the Canadian system, and even though I had a great plan, it still felt like a horror show. Many of my friends and colleagues, despite going through many of the same weird bureaucratic time-wasters I had to, were rather less annoyed. Yeah, something else might be in theory better, my descriptions for them of the simplicity of the Canadian system sounds pretty nice, but this is the way it’s worked here and, they tell me, “I don’t want to rock the boat while my children are still on my plan, don’t you understand? And that guy from Vancouver tells me that his parents had to wait in line for their MRIs.”)

    Get your sentimental memes and your soft-focus glurgy camera work in order this time. If it is as bad as they say, there *might* be another shot. If Obamacare hadn’t passed, there wouldn’t have been even a glimmering of a chance at another shot, possibly for decades. The issue would have been poison. Because yes, the elite was never going to put a bullet in the head of private insurance in one swell foop, and it cost them nothing to avoid doing it.

  42. Look, I gather what y’all really wanted back then and are still angry that you didn’t get, was a bullet to the head of for-profit insurance. Like, yesterday. What I don’t get is why anyone feels surprised and betrayed that, no, politicians in the country that currently defines itself on right-libertarian cultural memes—especially since Reagan—had no appetite for shooting a big chunk f the corporate sector in the head. I mean, they moved heaven and earth to bail out AIG or whatever, and most employed Americans aren’t getting financial services from Goldman Sachs, so why do you think they would kill Aetna?

    The very best you were going to get was a knife in the gut of for-profit insurance, and then letting it die slowly of blood loss and infection. But anyone who suggested such a thing is still held in contempt by various parties. Some people, you know, will be some people. So, Obamacare, and you will like it.

  43. MontanaMaven:

    Can someone explain what a public option would look like? i don’t get it. So you pay premiums to the government? Or you “buy” into Medicare like you do now?

    The closest examples exist in some European countries. In Germany, for example, if your annual employment income is above about 50K EUR, you can choose to be either publicly or privately insured. Public insurance is delivered via statutory sickness funds, of which there are many—they compete with each other as non-profit enterprises and run advertising campaigns and so on, though I don’t think they have private shareholders. They take a fixed percentage of salary, without any proportionalisation, but they cover as many dependents as required for the same amount.

    Private for-profit insurance is medically underwritten, which often results in premiums lower than public insurance for those permitted to be in it. Anyone making employment income of less than roughly 50K EUR is required to be in the public system with a statutory sickness fund. Anyone above 50K EUR who opts out of the public system requires special circumstances to opt back in (it’s not ALWAYS financially rational to leave the public system, since private insurance requires a separate policy per family member…).

    What this means is more or less that the working young and healthy subsidize the working old and the retired, and mostly within the working class. The rich are basically exempt from subsidizing workers, as they can waft off into the private system and avoid paying into the sickness funds. Nevertheless the mandate makes the German system more or less universal, with the cost much cheaper than the USA and with pretty good outcomes. Some doctors only take private insurance, but comparatively few. (There’s supplementary private insurance for those in the public system.)

    Some European countries have variations on this. I personally think that Canadian single-payer is more streamlined, but these systems develop according to the specific histories of these countries, not necessarily in a rational way, and are very difficult to change once set in place.

    I suspect the public option, if it had been implemented, would eventually have evolved into something like the German system, with the poor and middle class subsidizing itself as a (regressive) intergenerational transfer, and the rich being exempt. Of course, that would still liquidate a huge chunk of the US private insurance system, albeit more slowly than the instantaneous adoption of single-payer.

  44. BillH:
    Some 85% of the voters in this country had employer provided health insurance, and they emphatically did not want “Medicare for all” to take over.


  45. markfromireland

    When you are dealing with bad people, you must assume bad faith; bad behavior. You must plan for it.

    Actually I’m going to save that text as a link so that I can quote it repeatedly.


  46. Proof?

    Partly depends on which question you ask. And when, of course.

  47. Celsius 233

    @ markfromireland
    November 16, 2013
    Actually I’m going to save that text as a link so that I can quote it repeatedly.
    “When you are dealing with bad people, you must assume bad faith; bad behavior. You must plan for it.” Ian
    Coming from you that is surprising.
    Why? Because from what you’ve posted, I would have expected you would have already known and accepted that truism.
    Not a criticism; more an observation of many past posts and front-line experiences from you.
    That said, I have also bookmarked that phraseology. It does speak volumes, no…

  48. I have said from the beginning that Obamacare would be pecked to death before it began. We can expand Medicare to everyone without raising taxes, by creating a national network of genuinely nonprofit clinics and member-owned health plans. This will cut HMOs out of the deal, reduce administrative overhead, and convert the system from greed to generosity. My book “Health Democracy,” based on Ithaca’s successful co-op, explains how:

  49. Beleck3

    what is also astounding to me is to watch Obama. there is almost no direct involvement from Obama when it comes to his “legacy”. it must be money Obama is after, because if he cared about his “signature” achievement/Obamacare, i’d think he’d fight tooth and nail to implement/correct any mistakes that occurred. lol

    Obama seems so detached about the whole process of being President. watching Sibelius and the rest of his underlings deal with the fall out, well, it’s apparent how little Obama cares, period. but then again, Obama has always been a branding tool to get the Elites’ business done. that the Democrats are being openly used, just like the Republicans use their base, just shows the true “Owners” behind everything.

    that we are all fodder for the Business machine doesn’t appear to be within the consciousness of the average Joe. or is it willful ignorance? watching every subgroup being used as a tool, just shows how efficient the Propaganda is.

    i can’t imagine anything like Single Payer happening anytime soon, with 40-50 years of Rightwing PR, the idea that we are all in this “earth/society” together is an anathema to most Americans. after all, if it isn’t sold to Americans are profit worthy, it is not even considered.
    “i’ve got mine, go Fuck yourself” is still the predominant American ideal.

    healthcare is one area where the Right has successfully monoplized the conversation. even though Canada, being next door, and Europe, have proved that alterntives like Univeral Health Care/Single Payer exist. and we even have a form of Universal Health care for US Veterans!!! how’s that for controlling the conversation?

    truly an exceptional place, America. so devoid of any soul, brains or of any alternate reality.

  50. markfromireland

    @ Celsius 233 November 17, 2013

    Oh believe me I’ve long accepted and believed it as a result of seeing how people behave. I also believe that observing how people behave is a good guide to their character and how I should behave towards them. When there’s a disparity between how someone talks and how they behave then behaviour is the indicator to go for. Mark Twain’s crack about a politician:

    “The more he spoke of his honour the more we counted the silver spoons”.

    Sums it up pithily.

    It’s just that the next time that somebody, for example, tries to pretend that they have qualifications and experience that they manifestly do not have and then complains that I’m not interested in dialogue with them I’m looking forward to writing and “after all as our host says … … … ”


  51. S Brennan

    Beleck3, this is not ignorance problem of the general populous, no, “liberals” have only themselves to blame. Whether the ignorance of “liberals” is through conscious effort or natural predilection, it is they who drag the nation down. As I said earlier:

    “Again, none of what will become known as the most corrupt administration in 90 years would have been possible without his faithful followers. O’Bomber was a paid tool and he did what all corrupt pols do. What made O’Bomber powerful was the UNQUESTIONABLE FAITH of his followers. It is those quislings that are the rot of our society, even today they deny and obfuscate for their “dear leader” the “light giver”…pathetic.”

  52. David Kowalski

    I used to believe that when America got into really bad trouble every 70 years or so we somehow got a great President. It worked for Lincoln and FDR but won’t happen again.

  53. S Brennan

    2008 was such a year, a year that could have restored and healed, our rulers knew this and were very worried. Thanks to the mental laziness of what passes for the American “intellectual”, the moment was passed in favor of a second glance in the mirror, a moment of pure self-admiration. Ah…does anything compare with feeling good about oneself?

  54. HVD


    Inasmuch as you reference me in your last post I wonder if you would give me the opportunity to explain my credentials. There are reasons why I would not like to make them public. Perhaps through the good offices of our host I can explain myself privately to you.

  55. Hvd

    Our host certainly has my email – I would welcome a correspondence from you via that medium.

  56. Ian Welsh

    Up to MFI, if he wants to, I can put you in touch.

  57. Hvd

    Thank you Ian.

  58. Ken Hoop


    November 14, 2013

    Yes. To everything you’ve written. And, it’s criminal to it’s core because it did not have to be this way. My first measure of Obama was when he did a turncoat on holding the telecoms accountable for surveillance.

    A better first measure of Obama could have been taken when he voted to bail out the banksters.

  59. markfromireland

    Ian Welsh November 18, 2013

    By all means. Be aware that I’m about to go on my travels which means that it’ll be a few days before you get a reply.


  60. hvd

    Thank you MFI

  61. David Kowalski


    There is some intelligence in the U.S. Unfortunately, it has either sold out (Obama) or is ignored.

  62. It was a pleasure to find this blog, as I had lost track of Ian.

    Anyways let me track back to the exchange between Benedict and Ian on private insurance companies.

    I have worked for insurance companies and also sold individual health insurance. So I have been ‘on the inside’, even while my own sympathies are with Medicare-for-all.

    Individual and small group health insurance in the US has been essentially a free market.
    By that I mean that purchasing insurance is voluntary, and it is also voluntary for corporations to offer the product.

    Any time insurance is voluntary, it will not be universal. Some part of the public will not buy it, or they will buy it and let it lapse, etc. In markets like LTC and disability insurance, about 90% of the public does not buy it. This is true whether insurance companies are nice guys or bastards.

    Of those who do not buy the product, some will have a catastrophe and wish that they had it. Society will wish that they had it too.

    There are three approaches to this problem in health care:

    a. Herbert Hoover/Mitt Romney voluntarism — let charities take care of the uninsured

    b. safety net social insurance — expand Medicare and Medicaid

    c. Force people to buy private insurance and keep it, but regulate private insurance and subsidize it to make it affordable.

    Going with Option B in a time of large budget deficits means that you really have to raise taxes.
    This was politically impossible in 2009 for Obama and the Dems.

    So they went all in on Option C. It will probably fail. Our central government has much less power than Germany’s or France’s.
    I only hope that people remember Option B — this blog is keeping the flame I think.

    Bob Hertz, The Health Care Crusade

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