I don’t see how Obamacare can work

I don’t see how the Affordable Care Act, aka Obamacare, can work.  It’s too complicated.  It provides too many openings to game and undermine the system.  It doesn’t get at the causes of out-of-control health insurance costs.

obamacare_screw_o_1There are good things in Obamacare—the provisions that you can’t be denied medical insurance for a pre-existing condition; that grown children continue to be covered by their parents’ policies until age 26; that insurance companies can’t set a lifetime limit for coverage.

But the employer mandate gives an incentive for companies to avoid health insurance costs by cutting workers or cutting hours so that they are exempt from the bill.  The individual mandate give the health insurance industry a captive market without any protection against overcharging or underinsuring.

The Republican right wing’s war opposes Obamacare for exactly the wrong reason.   They oppose Obamacare not because it can’t achieve it’s stated goal of providing adequate medical care for all Americans, but because they are opposed to that goal.

President Obama actually is helped by the kind of enemies he has.  It makes his medical insurance plan seem better than it is.   That’s one reason I was willing to give Obamacare the benefit of the doubt when it first was proposed.  I thought that anything so vehemently opposed by the likes of Sarah Palin and Rick Perry must have something good about it.

The best thing I ever read about American health care was T.R. Reid’s The Healing of America,
written in 2009.  He compared the U.S. health insurance system with those of Canada, Britain, France, Germany, Japan and other countries, and tried to figure out why those countries were able to provide coverage for everyone while spending less for medical care than the United States did.

   He found three main reasons.

  1. Physicians and other medical professionals are paid more in the United States than in other countries.  Part of the reason is that they need sizable incomes to pay back student loans while medical education in most other advanced countries is free to those who qualify.
  2. Other advanced countries regulate drug prices, while the United States does not.  As a result, the drug companies only charge for their variable costs in those countries while they cover their fixed costs by what they charge Americans.
  3. The United States is one of the few companies that allow for-profit insurance companies to get between patients and physicians.  The financial incentive for these companies that that the less they pay out in claims, the higher their profit.

All these countries have different but unified systems while the United States has a patchwork of systems.  The U.S. Medicare system, which insures the elderly, is like the Canadian Medicare system, which insures everyone.  The U.S. Veterans Administration, in which government doctors care for veterans, is like the British National Health System, which covers everyone.  Employer-based health insurance in the United States is like health insurance in France and Germany, except that the insurers are labor union or non-profit organizations and cover everyone for the same fee.

During the 2008 Presidential campaign, Senator Hillary Clinton proposed a single-payer system, which essentially was a version of Canada’s Medicare system.  Senator Barack Obama, as an alternative, proposed a voluntary public option, in which a government system would provide health insurance to everyone who could afford private insurance.

Once in office, President Barack Obama abandoned the public option and endorsed the Affordable Care Act, which has come to be known as Obamacare.  This law did nothing to control the cost of medical care, including drug prices.  It locked for-profit insurance companies into the system.  And instead of simplifying an over-complex system, it complexified it even more.

The key part of Obamacare was the individual mandate.   The idea was that there are two groups of people without health insurance—old, sick and poor people who can’t afford health insurance, and young, healthy and rich people who think they don’t need it.  If you put both groups of people into a common pool, then in theory you could provide health insurance at a rate that the first group of people could afford.

This would require strong regulation and micro-managing of private insurance companies, which evidently isn’t going to happen and may not have been workable anyhow.

On top of this there is another problem—the relentless attack by right-wing Republicans who don’t think that medical care should be regarded as a right to begin with.   Unfortunately the complexity of the law provides many opportunities to undermine it and discredit its stated purpose.


Underinsured in the Age of Obamacare by A.W. Gaffney in In These Times.  The Affordable Care Act does not make health care a right.

Obamacare’s employer mandate shouldn’t be delayed.  It should be repealed by Ezra Klein in The Washington Post.

A huge Medicaid gap looms in Obama health care law by the Associated Press.  Two out of three people who would have qualified for expanded Medicaid coverage won’t get it because their state governments opted out of the program.

In U.S., 43% of Uninsured Unaware They Must Get Coverage by the Gallup Poll.

The Mess That Is Obamacare by Charles Pierce in Esquire [Added 7/5/13]

How is another year going to fix the employer mandate? which is part of continuing good coverage by the Corrente web log.


So what is the way forward?  I think unfortunately Obamacare is going to be around a long time, stuck in a deadlock between conservative Republicans who want to get rid of it, liberal Democrats who want to fix it and vested interests determined to maintain the status quo.

I favor expanding Medicare to less-old age groups and expanding Medicaid to less-poor income groups and raising what taxes are necessary to cover the increased cost.   Beyond that, I don’t know.

Is it too early to give up on Obamacare?  Am I being too hard on President Obama?  What do you think?

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7 Responses to “I don’t see how Obamacare can work”

  1. tiffany267 Says:

    My opinion is that medicine, like all goods and services, ought to exist in a free market. I think doctors should all go to private-pay practice and people need to take their health into their own hands. Insurance needs to return to what it was intended for – emergencies. That’s how it originated, and that’s what it ought to be used for – not for a nose drip or drugging your kid due to an imaginary attention disorder.

    Drugs should all be OTC. If people want a doctor’s opinion on their medication – fine! Have them call their physician and ask their opinion.

    Medicare, Medicaid, and the VA system should all be privatized ASAP.

    It is unconscionable to force the healthy to pay for the unhealthy, particularly in a country where most of the health problems are SELF-INDUCED.

    Let’s read from the Mayo Clinic’s Top 10 Biggest Health Problems in the U.S.:

    “The best ways to prevent septicemia are to wash your hands often, seek medical care for any infections in the body and to change tampons often and avoid using tampons that are more absorbent than you need.” – insurance cannot protect you from washing your hands and using the right tampons.

    “[Kidney disease] can be caused by high blood pressure or diabetes, according to the Mayo Clinic. The American Diabetes Association stresses the importance of keeping your blood sugar under control if you are a diabetic in order to prevent kidney disease.” – nuff said.

    “Wash your hands frequently and get a flu vaccine each year as recommended by your doctor.” – Flu vaccinations cost $25 at the grocery store, and local clinics will offer them for free.

    “Lose extra weight, exercise and eat a healthy diet to prevent diabetes.” – These are simple, easy, sensible lifestyle choices, folks. No one’s fault but your own for not taking a 30 minute stroll every day and eating nutritious food.

    “the leading cause of fatal injuries in both men and women is motor vehicle accidents. Wearing your seatbelt, driving safely and not mixing alcohol and driving can prevent these accidents.” – I’ll grant you, this advice doesn’t help safe drivers or pedestrians who are struck by drunk drivers. That being said, doesn’t car insurance cover accident-related injuries?

    “The National Heart, Lung and Blood Institute recommends quitting smoking to prevent COPD, as it is the largest risk factor.” – No one else put that cigarette in your mouth.

    “Lifestyle changes that can reduce your risk of stroke, according to the Mayo Clinic, include quitting smoking, losing excess weight, exercising and eating a healthy diet.” – duh.

    “Reduce your risk of cancers by not smoking, eating a healthy diet, using sunscreen and getting regular cancer screenings.” – Of the things on this list, cancer is the one thing that is often not the fault of the patient, though it sometimes can be. Breast cancer in particular affects all types of women (and even men) with all types of lifestyles, and it’s a scary disease! That’s why I donate to breast cancer charities searching for a cure.

    “For both men and women, heart disease kills the largest number of Americans per year. According to the American Heart Association, heart disease, which causes heart attacks and strokes, kills more people ***than all forms of cancer combined***. Quit smoking and eat a diet low in fat and sodium to cut your risk.” – (emphasis added by me) Wow. So you’re saying the largest killer of Americans could be eliminated just by eating right? Whodathunkit.

    We have this cultural image of the pitiful sick child who will die alone unless we all are forced to pitch in to save them. That’s just not the reality. Yes, there are certainly some children who need help, but by and large our socialized insurance programs are money down the drain spent on lazy people who couldn’t be bothered to eat right, stop smoking, and just take care of themselves.




    PS I do sympathize with your annoyance at Republicans. Romney is a great example – “OBAMACARE IS EVIL! Never mind that I pioneered the same system in Massachusetts!” There’s a lady running for Congress in NJ – she wants to repeal the “Affordable Care Act” yet has no plans to do anything with the other socialized insurance programs out there. Republicans speak out of both sides of their mouth, and it’s irritating.


  2. Anne Tanner Says:

    Your plan would work, Tiffany, but only because it would kill so many ill, homebound poor elderly, veterans with mental disorders caused by injuries while defending you, etc. So only healthy folks like you would be left. Sorry, I don’t want to live in that world.


    • tiffany267 Says:

      Hi Anne,

      I don’t like living in a world that sends people off to die halfway around the globe, ostensibly for the purpose of “defending me”. The last time that could have happened would have been WWII – since then there has not been a defensive war, only a great number of offensive nation-building projects and occupations which in fact make us less safe.

      Humor me, if you will, and please imagine for a moment that you live in Pakistan. You already face the day-to-day fears of gangs and Islamic fundamentalists as well as an inept government, though you personally want nothing more than to live your life peacefully and to raise your children safely. Then, it strikes. To kill. The drone, the missile without a face, that mercilessly murders your child. Without provocation, without even an explanation or a warning, it takes that innocent life, from thousands of miles away. The sheer cowardice is mindnumbing. THIS is the impression that the U.S. creates in foreign nations, thanks to the military, and we wonder why anyone would feel antagonistic?

      What would defend me would be a policy of no more state secrets and lies, no more militarism, and trade liberalization allowing peaceful commerce to be the mark we leave around the world (instead of thugs with machine guns).

      Returning to the question of older citizens’ health – having volunteered and worked in long-term care, I can personally testify as to the inferior care and quality of life of older people on Medicare (and to the exorbitant costs it places on everyone else). The way that healthcare facilities function is to host Medicare patients on which they know they will not make a ROI then to therefore overcharge all the other patients in hopes of making up the difference. Adding to the facility’s expense is the federal paperwork, which is so extensive they have to hire staff just to process it. So the first group that is punished is anyone that doesn’t qualify for Medicare, because they are paying much more than the facility actually needs to spend on them. Meanwhile, those who do qualify for Medicare are forced to sell their homes and anything else of value if they wish to stay in long-term care (that’s the law – you can’t get federal assistance and hold on to nice assets, which makes sense on paper). So any chance of them staying at home is ruined, and any chance of them ever leaving the facility is pretty much shot. That leaves them at the mercy of their caregivers, which sadly is not a good thing. Medicare facilities often provide more CNAs for their private-pay units and respond quicker to call-lights for private-pay patients. They are more likely to do needed maintenance on their private-pay units than to fix building problems in the Medicare units. Quite simply the level of care is better for private-pay patients, which of course is because the facility wants to keep their business in order to keep its doors open. Medicare patients, who lose everything to be stuck there without other realistic options, do not get the quality of care that other patients do. Meanwhile, most in the business know that non-Medicare facilities have higher quality of care for everyone (which of course makes sense since they don’t have to play the crazy game of making numbers work that simply do not work). I care a lot about elderly people, and that’s one reason I favor the privatization of these systems.


      Thanks for this discussion. Best wishes!


  3. philebersole Says:

    Tiffany, I’m pretty sure that the program you describe is Medicaid, the welfare program for low-income people, rather than Medicare, the the social insurance program for people age 65 or older. Medicare works well and everybody loves it, except that physicians complain that reimbursements are too low. Medicaid has a lot of problems.

    I am 76 years old. I have cancer, which is held in check by expensive hormone injections paid for by Medicare and supplemental insurance. I don’t have to dip into my savings in order to qualify for this.

    If and when I want to go into a nursing home, I would have to pay the expenses out of my own pocket until my savings are exhausted. Then and only then would I qualify for help under the state Medicaid program.

    This is subject to abuse. Middle class people sometimes give their assets to their children in order to qualify for Medicaid assistance for long-term care. In New York state and (I think) other states, you’ll be penalized for any asset you transferred for less than fair market value during the five years prior to applying for long-term care. A lawyer friend of mine does a lot of work in helping clients get around this requirement.

    Here are relevant links.




  4. philebersole Says:

    Tiffany, I think you make a good point about how insurance has taken over the medicine and how hardly anybody pays medical fees, only insurance premiums and payroll taxes.

    I am old enough to remember the days before Medicare, Medicaid and widespread employer-provided health insurance.

    Some physicians, who regarded medicine as a calling rather than a business, took on charity patients, or were easygoing about collecting bills from patients who were struggling financially, or took payment in terms of farm produce. And some charitable institutions provided free or cheap medical care for poor people, such as the Eastman Dental Clinic here in Rochester.

    Do you think that, if we eliminated Medicare, Medicaid and employer-provided health insurance, those days would come back? And, if they did, would that be enough to provide medical care for all those who need it – the people to whom Anne refers – homebound elderly poor people, children of homeless families, mentally ill people sleeping under bridges?

    In your comment, you didn’t say you are totally opposed to insurance. You said it should be reserved for medical emergencies and not for routine care. Maybe you’re right. Certainly my own insurance covers many things I could afford to pay myself.

    The problem is that this isn’t true for everybody. People who are struggling economically, and don’t have insurance, simply skip routine medical checkups and endure medical conditions that aren’t life threatening.

    I think you’re right to emphasize the importance of good habits, a balanced diet, exercise and a healthy style of life. To that I would add a healthy environment free of toxins and carcinogens.


  5. tiffany267 Says:

    Hello again,

    Thanks for the follow-up. You raise some excellent points as well, especially the question of toxins and carcinogens. It terrifies me that most consumers don’t seem to think twice about even the household cleaners they use! Or their hair products – and we won’t even get into the highly toxic industrialized food industry. (not to say ALL industrialized products are necessarily toxic, as there are increasingly healthier/greener alternatives on the market).

    As far as people who cannot afford care, my main thoughts are these:

    (1)There have always been people who have struggled economically, and I just don’t see our particularly charitable American culture throwing all of them under the bus just because healthcare insurance is taken out of the public coffers. There are already free dental and/or medical clinics in the towns near me that come to mind, and I imagine that it reflects a general trend. As much as Americans volunteer and personally donate compared to the rest of the world, I have no trouble seeing people finding some way to make sure others get their healthcare.

    As a feminist, I do take seriously that many women, especially mothers, are under such enormous pressure that they typically put their own health after that of their loved ones or just working to keep a family safe and happy, keep children in school, etc. Women are also disproportionately impacted by a great number of health conditions, which exacerbates the situation. I think that we ought to culturally place less pressure on women to get everything right for their families and we almost certainly could invest more into women’s health in general – but this doesn’t mean anyone should be forced to prop up those values.

    Mind you, within the system we have, I’d rather see women going to state-sponsored care at Planned Parenthood (which works excellently and costs the public a minuscule amount) rather than going through miles of red tape to obtain more socialized healthcare at traditional hospitals. Sadly, PP has trouble getting private donations because people are stupid about women’s right to an abortion (which is tragic because only about abortions only comprise about 3% of what they do anyway!). That’s one reason I don’t really scream about them getting public money – the way things work now PP actually saves us money.

    You say – that all sounds lovely but it doesn’t help folks who rely on expensive treatments for severe conditions (like cancer). Which leads to (2) I think most healthcare would logically become more affordable if we didn’t have such a challenging regulatory environment for medicine to enter the market. I recently had conversation with a long-time pharmacist, who said it takes about 10 years and millions of dollars for a medicine to become commercially viable, even if it uses proven technology, due to the FDA’s regulatory policies. Considering our federal government’s track record with impartial regulation of business (LOL severe understatement, much) I simply cannot believe that this process is keeping us all safe.

    I also think in general that freer markets would lead to greater innovation not just in medicine but in all aspects of our lives, which would almost certainly lead to more treatments and cures for more conditions.

    Incidentally, I hope this comment makes sense, as I am writing it on about two hours of sleep LOL. I’m sure I sounded callous to Anne, but I don’t like when people attack a position by saying all I want to do is kill old people, which clearly is quite far from the truth.

    Thanks for a much more respectful conversation. Also, I wish you the best with your condition. One thing that spending time with the elderly (as well as the disabled, with whom I volunteered for a number of years) has taught me is to appreciate that life is beautiful even with impairments. In fact often it is our physical adversities that show our personal strength.

    Best wishes and look forward to reading more.


  6. philebersole Says:

    Tiffany, thank you for your kind thoughts. Actually I am very fortunate. Unlike many older people, I don’t suffer from chronic pain, I don’t have problems with mobility, I don’t have foods that I can’t eat (although I am by choice more careful about my diet than I used to be.)

    I go for days at a time without even thinking about having cancer and, when I do, I feel thankful to be alive, because I very easily could not be. I am thankful that I live in Rochester, NY, a center of cancer research, where excellent treatment is available. I am thankful that I live in an era of rapid advances in medical knowledge. And I am thankful that I have good health insurance—and I wish everybody did.


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