Archive for the ‘Health Care Reform’ Category

Doug Muder on how health insurance works

March 13, 2017

Poor People Need BETTER Insurance Than the Rest of Us, Not Worse by Doug Muder for The Weekly Sift.

Why do things cost so much?

February 17, 2017


Scott Alexander, a physician in the Midwest, points out on his blog that during the past 50 years—

  • U.S. housing costs have increased about 50 percent.
  • U.S. education costs have increased 100 percent
  • U.S. college costs have increased 400 percent.
  • U.S. subway fares have increased 400 percent or more.

All of this is adjusted for inflation.

  • Health care in the United States costs about four times as much as equivalent health care in other First World countries
  • U.S. subways costs about eight times as much as equivalent subways on other First World countries.

The wages and salaries of public school teachers, college professors, nurses and physicians has meanwhile remained relatively flat.

As Alexander points out, this is strange.


Trump moves fast to strike at Obamacare

January 21, 2017

President Donald Trump, in his first day in office, issued an executive order to cripple the administration of the Affordable Care Act.

trumppositionThe order (1) forbids administrators to issue any new order or regulation that imposes new costs on states and (2) authorizes administrators to suspend any order or regulation that imposes undue costs on individuals or states.

The limitations are that the change has to be permitted by law and that there have to be advance note and public comment on the changes if the law requires it.

That may sound relatively harmless, but the ACA is so complicated that it is hard to make it work and easy to make it cease functioning—like removing a couple of bolts from a highly complex machine.

Here are some of the things reporters said could happen under Trump’s executive order:

  • Delay indefinitely enforcement of all the individual and state mandates to buy or provide health insurance.
  • Expand hardship exemptions under the individual requirement to buy health insurance so that they cover virtually everybody.
  • Extend the option of state governments to approve health insurance plans that don’t meet all the requirements of the ACA, including refusal to refuse insurance to people with pre-existing conditions.

Another thing the Trump administration could do is to stop defending a lawsuit by the House of Representatives challenging the legality of a program to reimburse insurers for providing subsidies for low-income patients.   The program was authorized by law, but no money was ever specifically appropriated for it.   The U.S. District Court agreed the program is illegal; the case is now on appeal to the U.S. Court of Appeals.


Will the GOP repeal the Affordable Care Act?

January 18, 2017

Update 1/19/2017.  It seems that in fact the Congressional Republicans do have an alternative of sorts to Obamacare.  A link has been added to this article.

The top video from Vox is about Kathy Oller, who lives in southeastern Kentucky and has a job signing people up for the Affordable Care Act.  It tells why many people in her area think the cost of the ACA is too high, and why they voted for Donald Trump.

The bottom video is about an interview of President Barack Obama by Vox reporters on the topic of health care.  Kathy Oller came along.  Her question to President Obama and his answer begin at the 37th minute and take about eight minutes.

President Obama is right in saying Republican leaders are irresponsible in proposing to repeal the ACA without having a replacement plan in place, and in challenging them to come up with a better plan.

It’s apparent that the Republican leadership doesn’t have such a plan..


Speaker Paul Ryan will try to privatize Medicare

November 19, 2016

Speaker of the House Paul Ryan will try again to privatize Medicare.

President-elect Donald Trump said during the campaign that he will protect Medicare as it is.

Speaker Paul Ryan

Speaker Paul Ryan

But Ryan doesn’t seem to expect a fight with Trump.  Why not?  Does he have reason to believe that Trump didn’t mean what he said?  Reporters need to press Trump to declare where he stands.

Grass-roots advocates should not stand by idly and assume the Democrats in Congress will defend Medicare.  They should be letting their congressional representatives and Senators know that tampering with Medicare is unacceptable.

I give Ryan and the Tea Party Republicans credit.  They never give up pushing for their goals.  They take ideas that seem radical and make them mainstream.

And they strike when the iron is hot!  They never hesitate to use whatever power they have to advance their agenda.

Liberals and progressives can learn from their example.  Instead of just passively trying to preserve Medicare and also Obamacare as they are, they should be demanding a Medicare-for-all system to replace Obamacare.


How many Americans still lack health insurance?

April 4, 2016



Source: Charles Gaba’s Blog

Hat tip to Avedon’s Sideshow

A blogger named Charles Gaba has figured out that, under Obamacare, slightly over 294 million Americans now have health insurance, but 29 million are still without—about 9 percent of the population.

The striking thing to me is how much work he had to do to come up with a plausible estimate.  I would have thought that the U.S. Department of Health and Human Services  had that figure on a web site somewhere.

I would have thought that, in general, President Obama would do more to ensure careful management of his signature reform, given how complicated it is and given how determined his Republican political enemies are to make it fail.

Click on Charles Gaba’s Blog for a detailed breakdown of the figures and an explanation of how he arrived at them, and a larger, higher-resolution version of the chart.

When Bernie met Hillary: 1993

June 19, 2015

At the start of 1993, the newly-elected President Bill Clinton appointed his wife, Hillary, as head of his Task Force on Health Care Reform.

Rep. Bernie Sanders of Vermont, the lone socialist in Congress, advocated a single-payer health insurance system—basically, Medicare for everyone, as in Canada.

Hillary Clinton in 1993

Hillary Clinton in 1993

In February, Sanders requested a meeting with Hillary, “to bring in two Harvard Medical School physicians who have written on the Canadian system,” according to the records of the administration’s task force.  Those physicians were Stephanie Woolhandler and David Himmelstein, leading advocates for single-payer health care.

They got their meeting at the White House that month, and the two doctors laid out the case for single-payer to the first lady.

“She said, ‘You make a convincing case, but is there any force on the face of the earth that could counter the hundreds of millions of the dollars the insurance industry would spend fighting that?’” recalled Himmelstein.

“And I said, “How about the president of the United States actually leading the American people?’ and she said, ‘Tell me something real.’


Political reporter Ben Schreckinger said Sanders got the brush-off, the Clinton administration introduced a complicated plan limited to altering the existing health insurance system, the health insurance industry fought it anyhow, and the plan went down to defeat.


When Bernie Sanders met Hillary Clinton by Ben Schreckinger for Politico.

The fatal flaws of Obamacare

February 17, 2015

obamacare_screw_o_1When the Affordable Care Act was enacted five years ago, I was aware of its flaws, but I thought it represented an advance over what we had before.

Obamacare did give access to health insurance to millions of Americans, including people with pre-existing conditions, who otherwise wouldn’t have been able to get it.   The tradeoff was that it created a captive market for the health insurance companies to provide bad insurance.

My e-mail pen pal Bill Harvey sent me a link to an article by a Dr. John P. Geyman for the International Journal of Health Services which, in my opinion, sums up the problems with Obamacare very well.

  1. Health care “reform” through the ACA was framed and hijacked by corporate stakeholders.
  2.  You can’t contain health care costs by permitting for-profit health care industries to pursue their business “ethic” in a deregulated marketplace.
  3. You can’t reform the delivery system without reforming the financing system.
  4. The private health insurance industry does not offer enough value to be bailed out by the government.
  5.  In order to achieve the most efficient health insurance coverage, we need the largest possible risk pool to spread risks and avoid adverse selection.

Dr. Geyman thinks the answer is a single-payer health system, financed by taxes which covers everyone.  Such a system would be cheaper for most people than a private system because it simplifies administration and subtracts the need for profit.

One reason why such a system wasn’t considered in 2010, in addition to the entrenched power of pharmaceutical and health insurance lobbyists, was that many Americans were satisfied with their existing insurance and didn’t want to risk an unknown system.

Now private insurance has changed for the worse for most people.  Unfortunately, it will be very natural for people to see the inadequacies of Obamacare as an argument against any government health insurance plan at all.


A Five-Year Assessment of the Affordable Care Act: Market Forces Still Trump the Common Good in U.S. Health Care by John P. Geyman for the International Journal of Health Services.   (Hat tip to Bill Harvey)

The passing scene: January 3, 2015

January 3, 2015

Social Programs That Work by Ron Haskins in The New York Times.

Many social welfare programs fail.  The Obama administration has identified some that succeed.   While this does not change my unfavorable opinion of the President’s policies overall, I think he is entitled to credit for having this research done.

This City Eliminated Poverty and Nearly Everybody Forgot About It by Zi-Ann Lum for Huffington Post.

Between 1974 and 1979, the small city of Dauphin, Manitoba, guaranteed all residents a basic income—employed or not, able to work or not.  What was the ultimate outcome of this radical experiment?  Nobody ever bothered to check and find out.

What’s Wrong With Georgia? by Alana Semuels for The Atlantic.

Scott Walker has failed Wisconsin and Minnesota is the proof by Jimmy Anderson for the Milwaukee Journal-Sentinel.

Georgia and Wisconsin are the latest American states to discover that a Third World economic strategy—low wages, low taxes, low services and low regulation—is not a successful formula for creating jobs and promoting economic growth.


Vermont gives up on single-payer health plan

December 18, 2014

Vermont Governor Peter Shumlin announced that he has given up on a plan to introduce a single-payer medical insurance plan—Medicare for everbody—by 2017.

medicareforall_nThe plan, known as Green Mountain Care, would have cost too much in payroll taxes and would not have generated big savings in medical and insurance costs, he said.

I don’t think the Affordable Care Act is satisfactory, and I would have liked to see Vermont prove that single-payer is a workable alternative by launching it successfully on the state level.

Maybe I’m wrong.  Maybe single-payer, despite the success of Medicare-for-all in Canada, isn’t feasible in the USA.  But I hate to think that Obamacare is the best we Americans can do.


Vermont bails on single-payer health care by Sarah Wheaton for Politico.

Shumlin Ends Single-Payer Push by Dave Gram for Valley News of White River Junction, Vermont

Vermont’s Giving Up on Single-Payer Health Care Over Ballooning Costs by Sarah Hurtubise for The Daily Caller.

Shummy’s Surrender: Democratic governor of Vermont goes south on single-payer by Steve Early for Portside (hat tip to Bill Harvey)  [added 12/19/14]

The passing scene: November 8, 2014

November 8, 2014

What the Election Means for the Republican Brand by Daniel McCarthy for The American Conservative.

Can a party philosophically defined by Fox News win millennial voters and the electorate of the future?  Daniel McCarthy wrote that they can win only if there’s no-one well organized enough to complete with them.

The well-oiled machinery of movement conservatism remains in the hands of those who think the only trouble with George W. Bush is that he didn’t go far enough, McCarthy wrote.

Lame duck Obama’s brave new world by Pepe Escobar for Asia Times.

Election of a Republican majority in the Senate means no possibility of agreement with Iran on nuclear weapons and fighting ISIS, no possibility of agreement with Russia on Ukraine and Middle East issues, and no possibility of action of climate change.

On the brighter side, Republicans, out of spite, will probably the Trans Pacific Partnership agreement, with its investor-state provisions to block environmental and financial regulation.  The one thing the GOP and Obama administration will agree on is the so-called global war on terror.

As US and China meet at APEC summit, a drama involving billions in trade by Peter Ford for Christian Science Monitor.

China, which is excluded from the proposed Trans Pacific Partnership agreement, will launch a Free Trade Area of the Asia Pacific agreement as an alternative.  All 21 members of the Asia Pacific Economic Cooperation group will be eligible to join.

The New York Times doesn’t want you to understand this Vladimir Putin speech by Patrick L. Smith for Salon.

The Hidden Author of Putinism by Peter Pomerantsev for The Atlantic.

Vladimir Putin is right to insist on the rule of law in international affairs for everyone, including the United States.  The fact that the rule of law is not observed in Russia’s internal affairs is a separate question.

The Hospital’s Duty of Care by Greg Pond for MRSA Topic, a blog devoted to infectious disease.  (Hat tip to Mike the Mad Biologist)

About 8,000 Canadians die every year of hospital-acquired infections.  That’s because physicians and nurses are too under-staffed and over-worked to have time to wash their hands after every interaction with patients.   I’m sure that U.S. hospitals are no better.  This is a much more serious public health threat to North Americans, at this point, than Ebola.

Why is the GOP afraid of Obamacare?

July 24, 2014


I’ve long been of two minds about  Obamacare.   Sometimes I think it is a complete mess and sometimes I think that, despite its complexity and obvious flaws, it will be of net benefit to the American public.

There is one group of people who’ve made up their minds about it, and that is the Republicans who are determined to prevent implementation of the Affordable Care Act by any means necessary.

If they believed the law is as terrible as they say they do, the smart political strategy would be to allow the law to go into effect, allow the public to see how bad it is and then move to repeal or amend.

The only explanation is that they don’t dare let this happen because they think that, once Americans experience the new law in operation, they will embrace it and vote for Democrats forevermore in gratitude.

‘If living was a thing that money could buy…’

July 7, 2014

If living were a thing that money could buy

Then the rich would live and the poor would die

via Joan Baez.

Rich people on average live longer than poor people, for many reasons.  On average, they grow up in less toxic environments, they lead less stressful lives, they have more time to devote to exercise and they have better choices about diet.

Life expectancy overall is increasing, and 80-somethings such as movie director Clint Eastwood and Senator Dianne Feinstein as active and productive as people in previous generations who were 20 years younger.

But for certain segments of the population—white people who haven’t completed high school, for example—life expectancy is actually dropping.

Frederik Pohl_1976_GatewayLinda Marsa, writing in Aeron magazine, describes longevity research that may widen the life gap between rich and poor.  Scientists are studying the genetic basis of aging with a view to using genetic material to slow down or actually reverse the process of aging.   These treatments will be expensive, at least to begin with, and unavailable to those who can’t pay.

Science fiction writers have already explored the implications of this.  Frederik Pohl, in his short story, “The Merchants of Venus” (1972) and novel Gateway (1977). described a society in which life could be prolonged almost indefinitely but only for those who can afford to pay.   The protagonist of “The Merchants of Venus” has a bad liver, and is trying to make enough money to buy a transplant before it goes bad.  Talk about living paycheck to paycheck!

The alternative to allocating scarce medical resources on the basis of money is to allocate them on the basis ofholyfire.n5489 merit.  That is the situation in Bruce Sterling’s Holy Fire (1996).  The 94-year-old protagonist is granted access to life extension technology on the basis of good health habits (she has little sympathy for her ex-husband, an addicted cigarette smoker) and her positive contribution to society, which consists of serving on boards and commissions having to do with health care policy.

She is allowed to participate in a clinical trial of a drug that supposedly will restore youth, but the drug affects her mind and she breaks with her cautious life.   At the end, she loses her privileges and comes to terms with mortality.

I’m not attracted by either alternative, but I don’t have a better one.  If something is scarce, then by definition it can’t be provided to everyone.  And maybe over time the medical treatments available only to the rich, or to people with good connections to the medical research establishment, will become available to everyone.


The new normal: Links & comments 6/22/14

June 22, 2014

Thrown Out of Court: How corporations became people you can’t sue by Lina Khan for The Washington Monthly.

Individual Americans are losing their right to sue large corporations by means of “terms of service” contracts that customers and employees are required to sign as a condition of doing business.   By signing these contracts, individuals give up their right to take their complaints to a judge and jury and instead agree to abide by the decision of a corporate-friendly arbitrator.

Corporations have been complaining for years about the burden of litigation, and, back in the day, I fell for this.   But even then, the courts were busier with lawsuits by corporations against each other than they were lawsuits by individuals or by class-action suits.

Owners and managers of corporations already have a privilege denied to ordinary citizens, which is limited liability for their debts and fines.  We are getting far beyond the question of whether corporate entities have the same rights as individuals.  By means of this 21st century version of the “yellow-dog contract,” they are becoming mini-governments.

Hillary Clinton forgets the ’90s: Our latest gilded age and our latest phony populists by Thomas Frank in Salon.

When Bill Clinton ran for President in 1992, he ran as the advocate of working people against the corporate interests who didn’t play by the rules.  What we got was Ronald Reagan with some of the sharp edges filed off.  As Thomas Frank wrote in Salon today, the Clinton Presidency was an era of corporate mergers, financial deregulation, downsizing of government and NAFTA

That’s what we’re likely to get from a Hillary Clinton presidency, too.  She voices the same populist rhetoric and has the same corporate allegiances.

The floor is open by Psychopolitik.

How committed are we Americans to democracy?  A Gallup poll indicates a “no confidence” vote in the institutions of democracy.   The institution in which Americans have the most confidence (74%) is the military and the one in which we have the least confidence is Congress (7%).   A majority lack confidence in the Presidency and the Supreme Court, but they have confidence in the police.

If I didn’t know better, I’d take that for a poll of Italians just prior to Mussolini’s march on Rome.

Every year, we waste Spain by Tim Stuhldreher.  Hat tip for this link to Mike the Mad Biologist.

U.S. Healthcare: Most Expensive and Worst Performing by Olga Khazan for The Atlantic.

If the U.S. spending per person for medical care were the same as a typical industrial nation, our annual health care budget would be more than $1 trillion less.   That’s the equivalent to the gross domestic product of Spain, out of which a nation of 47 million people feed, clothe, shelter, educate and amuse themselves, and, yes, also provide medical care.

Can a corporation have religious scruples?

March 23, 2014

Employers have brought a case before the U.S. Supreme Court claiming a religious conscientious objection to the provision of the Affordable Care Act requiring them to provide health insurance that covers contraception.  What they’re claiming, as I see it, that religious freedom includes the right to refuse to do business with sinners.

The general rule is that there is no right of religious exemption from laws for the benefit of the general public that apply to everyone equally.  Nevertheless, there is a tradition in the United States of bending over backwards to accommodate individuals with sincere religious beliefs, from allowing religious conscientious objection to military service to exempting Seventh Day Adventists from Sunday closing laws.

I think this is a good tradition, as it applies to individuals.  I don’t think, for example, that the right of gay people to marry includes the right to do business with a florist or wedding photographer who thinks homosexuality is sinful.

Corporations are a different matter.  Corporations are not human beings.  They are soulless artificial constructs whose supposed personhood is a legal formality.  How, then, can a corporation have religious scruples?   Why do the managers of a corporation have any more right to impose their private views on their employees than do the managers of a state Department of Motor Vehicles?

American exceptionalism in health care

January 28, 2014

1. prices_intl_nyt

Jon Perr explained for Daily Kos why Obamacare does not fix the dysfunctional U.S. health insurance system.

On January 1, 2014, the Affordable Care Act went fully into effect.  But for all of the furious fighting over the law these past five years, Obamacare was always an evolutionary reform grafted onto the existing American health care system.  The Medicaid public insurance program has been extended to roughly four million lower income Americans so far.  About two million more people have purchased private insurance, many of them aided by subsidies from Uncle Sam.

And while many (though not all) of the worst abuses that let insurers pad their profits by denying or dropping care for the sick have been banned, the edifice of private insurance remains largely intact.

Far from a “government takeover of health care,” Obamacare preserves all of the hallmarks—private insurance companies, private hospitals, private doctors, and the patchwork of different systems for veterans, seniors, workers, and the poor—that define the American model of health care provision.

Click on Why the U.S. should treat health care like a utility, not a market to read Perr’s full article.  Hat tip for to Bill Elwell for the link, which is the source of the charts.


Medicaid isn’t all that great a system

January 16, 2014

My preferred alternative to the present system and to the complexities of Obamacare has long been expansion of Medicare and Medicaid.  But after reading on the Corrente web site about one person’s experience in the Medicaid system, I have my doubgts.  Experience shows that any service that is means-tested to serve only poor people will be a bad system.  The best answer is Medicare for all.


Obamacare is not Heritage Foundation plan

December 7, 2013

Liberals like to point out that the Affordable Care Act’s individual mandate is the same as a proposal by the right-wing Heritage Foundation.  That is, everybody has to buy insurance from for-profit companies, but insurance in theory becomes affordable because the cost is spread out over a whole population of rich and poor, sick and healthy and old and young.

I, too, sometimes fall into the trap of saying President Obama’s plan as a whole is a warmed-over Republican plan, but, as Scott Limieux pointed out on his Lawyers, Guns and Money blog, this is not really so.


Of course it remains to be seen whether there really will be strict, federally enforceable consumer rights, or whether the ACA will simply create a new captive market for the health insurance industry.

And the historic expansion of Medicaid, which was a key part of the ACA, was sabotaged by the Supreme Court and Republican state governments, although that is not Obama’s fault and may eventually be overcome.

The important thing about the ACA is that there is no longer any point in speculating about its impact.  It is the law and will remain law until at least 2016, and that will be plenty of time to see whether it does more good than harm.

The passing scene: Links 12/3/13

December 3, 2013

Remove TEPCO Before Removing Fuel by Arnie Gundersen for Fairewinds Energy Education.

Racism Not a Problem Anymore? Don’t Be Ridiculous, It’s Still a Big Issue by Jamelle Bouie for The Daily Beast.

Vladimir Putin and the Limits of Thuggishness by Kevin Drum for Mother Jones.

A Challenge to the No Fly List by Ian Welsh.

Guns, Bombs and Weapons You Can Build at the Airport by Joe Flaherty for Wired.

New Study Finds Higher Methane Emissions From Fracking by Nick Cunningham for Oil Price.  Hat tip to naked capitalism.

How Wall Street Has Turned Housing Into a Dangerous Get-Rich-Quick Scheme—Again by Laura Gottesdiener for Mother Jones.

Conversation about Health Care No Longer Remotely About Health Care by Chris Bray for The Baffler.

The passing scene: Links & notes 12/1/13

December 1, 2013

The latest health issue for the elderly: ‘observation purgatory’ in hospitals by June McCoy for The Guardian.  Hat tip to naked capitalism.

Medicare’s payment structure gives hospitals an incentive to designate elderly patients as “observations” rather than “admissions.”  This means less care for the patient and higher bills for their families.

23andMe is Terrifying But Not for the Reason the FDA Thinks by Charles Seife for Scientific American.  Hat tip to naked capitalism.

The U.S. Food and Drug Administration has ordered a genetics testing company to stop selling its products until it can prove its tests are accurate.  But the writer says the real danger is creating a genetics database on millions of Americans that could be tapped by Big Brother.

Activist Malpractice by Michael Donnelly for Counterpunch.  Hat tip to Mike Connelly.

The writer slams Democrats, liberals and fake environmentalists who facilitate the Alberta tar sands mining, mining by mountaintop removal in Appalachia and clear-cutting of forests in Oregon.

Canada to file Arctic seafloor claim this week by the Canadian Press.

As the Arctic icecap melts, Canada, Russia and Denmark (which owns Greenland) are mapping their northern continental shelves and staking claims to the floor of the sea.  Canada’s claim will be the size of the provinces of Saskatchewan, Alberta and Manitoba combined.

Nicaragua canal boosts China power by Arnie Seiki for Asia Times.

China and Nicaragua have signed an agreement that would give China the right to build a canal across Nicaragua rivaling the Panama Canal.  While it’s long way from signing an agreement to actually building a canal, it is a sign of China’s emergence as a global power, and not merely an east Asian power.

Wal-Mart arrests could fuel “a new political movement of the disenfranchised,” Grayson tells Salon.

Where was President Obama’s due diligence?

November 27, 2013

Not long after I voted for Barack Obama in 2008, I came to realize that his priorities were different from what I thought they were.  And I soon saw that his health reform plan was deeply flawed and hard to implement.  But I nevert, until now, thought that he was incompetent.

butwewon'tThe Affordable Care Act is President Obama’s signature domestic achievement.  Compared to Medicare for all (single payer) or his own proposal for a public option, it is hugely complicated.  Moreover there are political enemies in state governments that want to make it fail, and special interests in the pharmaceutical and health insurance industries that want to milk it for their own benefit.

Under these circumstances, wouldn’t you think that he look for the smartest and most capable information technology manager he could find and give that person complete authority?  With his connections in Silicon Valley industry, he wouldn’t have had trouble finding such a person.  But evidently not.

President Obama’s right-wing opponents accuse him of creating “czars” to oversee government programs, but this was a case where a “czar” was necessary and sadly lacking.

And wouldn’t you think that he would check on the progress of the program early and often? The President, after issuing a non-apology apology, said, “I was not informed directly that the web site would not be working the way it was supposed to.”  This is a statement worthy of George W. Bush.  Why was he not informed.

During the George W. Bush administration, I blamed President Bush, Vice President Dick Cheney and Karl Rove for mistaking campaigning for governing, and public opinion polls for reality.  But when individuals so different in background and personality as George W. Bush and Barack Obama exhibit the same flaws, I have to think there is something deeply wrong with the U.S. political culture that goes beyond the character traits of individuals.


America needs something better than the ACA

November 11, 2013

blog_poll_kaiser_obamacare_november_2013Many more Americans want to keep the Affordable Care Act or make it stronger (47 percent) than want to repeal it or replace it with a Republican alternative (37 percent).  I do not venture to predict how they will think a year from now when the technical problems will (presumably) be resolved and the law will go into force.

House Speaker Nancy Pelosi was right.  We won’t really understand what’s in the law until it goes into operation.   I am sure that lives will be saved by forcing insurance companies to cover people with pre-existing conditions, and I hope that a lot more people will benefit financially than will be hurt.   But even if things work out for the best, Obamacare at best is deeply flawed.

New Medical Gatekeepers.   The ACA makes for-profit insurance companies the gatekeepers between physicians and patients.  The only way to have a doctor of your choice is to find an insurer that has that doctor on its roster.

Insurance companies get even greater leverage than they have now in imposing a corporate business model on physicians.  A physician who spends too much time on sick and needy patients will not be cost-effective from a business standpoint, and may be dropped from the roster.  This isn’t new, but Obamacare locks it in.

Controlling the Wrong Costs.   President Obama is cutting Medicare reimbursements to health care providers.  At the same time he has locked for-profit insurance companies into the system, and declined to negotiate with pharmaceutical companies to lower drug prices.

This is a typical example of how things work in American life nowadays.  The people who do things that create value are being squeezed.  The people who extract profits from what others create are left untouched.

It may well be that health care providers are overcharging Medicare.  I don’t have the facts and figures to express an informed opinion either way.  It does seem to me that, for example, $800 is a lot to charge for an ambulance ride.  But I might think differently if I knew what it cost to pay for and maintain a fully-equipped ambulance, to pay for and maintain the ambulance station, and what it costs to train and pay ambulance crews and keep them available 24 hours a day 7 days a week.

But it is obvious that there is no public benefit in going through a for-profit insurance company to get a benefit mandated by government, or in paying more for a drug than foreigners pay for the same drug.

Complexification.   One of the problems with the American health care system—a mixture of employer-based insurance, individual insurance, Medicare, Medicaid and veterans’ benefits—was its complexity.   The Affordable Care Act makes it more complicated, and I think that is the main reason why the Exchanges and sign-up system don’t work.

There would not be any problems in signing up if Congress had enacted a single-payer plan (Medicare for all) or, if that was not feasible, simply expanded Medicare or federalized and expanded Medicaid.  The voluntary public option proposed by Senator Barack Obama in 2008 would have been more difficult, but still simpler than what was advocated.


Obamacare: conservatism as the new liberalism

October 24, 2013


Even though I think the Affordable Care Act is a bad law, I’m opposed to most of the people who oppose the law.

Most opponents of the law are against it because they don’t agree with having the government guarantee a minimum level of medical care to all.  I’m opposed to the law because I don’t think it will come anywhere near to accomplishing that purpose.

Defenders of the Affordable Care Act point out that it originated as a conservative Republican plan, drafted by the right-wing Heritage Foundation and first implemented by Mitt Romney as governor of Massachusetts.

From my standpoint, that is the problem. I am a liberal Democrat who voted for Barack Obama in 2008, and I did not vote for him in order to advance a conservative Republican agenda.

I’m pretty sure that the Heritage staff did not offer up their plan because they felt an urgent desire to assure health insurance for everybody.  I think they proposed their plan as a way to avoid enacting Medicare-for-all, aka a single-payer plan.

The chief merit of the Obama / Heritage plan from the right-wing point of view is that it locks the for-profit insurance companies into the system and gives them a captive market, even though they add no value to medical care.  The threat of a universal system would be that there would be no role for the insurance cmpanies.

Back in 2008, the single-payer plan was the mainstream Democratic position. Both Hillary Clinton and John Edwards advocated it in their presidential campaigns.  Barack Obama offered a moderate compromise, a public option in which an affordable government insurance plan would be made available, which at the time that seemed reasonable to me.

But as soon as President Obama took office, he embraced the Heritage / Romney plan.   His staff ridiculed anybody who took his campaign promise seriously.

If Obama thought that this would bring the Republicans on board, he was sadly mistaken.  They reverted to what they really wanted all along, which is to do nothing or take away what we have.

In five years, the former mainstream liberal position has been taken off the table for discussion. The former mainstream conservative position has been redefined as the liberal position.  The extreme right-wing position which was not then on the table has been redefined as the mainstream conservative position.

Nobody really wanted Obamacare.  It was originally proposed as a lesser evil from the conservative point of view,  and it was enacted as being a lesser evil from the liberal point of view.   The right-wing Republican goal is to get rid of it altogether.   The liberal Democratic goal should be to replace it with something adequate.


The U.S. can do a lot better than Obamacare

October 24, 2013

The Affordable Care Act is a bad plan.  It may be a lesser evil than the system we had before, just as the system we had before was better than nothing at all, but it falls short of what Americans have a reasonable right to expect.

Obamacare creates a captive market for the for-profit insurance companies, which in themselves contribute nothing to the availability or quality of medical care.

It is a form of privatization of social insurance, which creates a bad precident—especially ominous in the light of President Obama’s repeated statements about the need to cut Medicare and Social Security.

By design, it does nothing to control some of the main things that make health care so expensive in the United States.  In addition to locking the insurance companies into the system, it allows pharmaceutical companies to charge Americans more than what they charge Canadians and Europeans for identical products.  And it complexifies the needlessly complex existing system.

Instead of providing a universal system, it creates a means-tested system where different people give different levels of health insurance, and some are still outside the system.

While the ACA provides subsidies to low-income citizens who can’t afford health care premiums, these may in the long run turn out to be mere pass-throughs that enable insurance companies to raise their rates, just as the Pell grants to college students eventually become mere pass-throughs to the colleges.

And while it assures insurance to many people who previously were denied it, I seriously question whether either competition or federal regulation will guarantee insurance premiums are affordable. Even if government regulators are serious about keeping insurance affordable, there are many ways for companies to game the system, by providing lower levels of care, asking higher deductibles and simply making it difficult to file claims (I have personal experience with the latter).

I do recognize that Obamacare has helped many people and even saved lives.   I don’t advocate wiping it off the blackboard and going back to the previous system.  But we Americans shouldn’t accept that this is the best we can do.


The not-so-Affordable Care Act

October 15, 2013

Double click to enlarge.

The cartoon tells how the Affordable Care Act is supposed to work.  Insurance companies are mandated to give health insurance to everybody who needs it.  Everybody is mandated to sign up for health insurance rather than waiting until they are sick.  The government will subsidize insurance for those who can’t afford it.

The problem is that Mr. Insurance Company can game the system.  He can raise premiums on Bob, Sam, Dave and Mary.  If premiums are limited, he can raise the deductible or restrict coverage—following the principle of raising the price of cereal by putting less cereal in the box.

Instead of shutting down much of the government, Congressional Republicans who oppose Obamacare would have been better advised to let it take its course.

The rollout of Obamacare has been a mess, but, because of the shutdown crisis, this has received little news coverage.  Cartoonist Ted Rall wrote last week in his syndicated column about his six-hour struggle to sign up for Obamacare on-line.   But the real problem was the Exchange’s menu of choices.

Talk about sticker shock.

NOT affordable.  Not, as Obama said, lower than your cellphone bill.

For this 50-year-old nonsmoker, New York State’s healthcare plans range from Fidelis Care’s “Bronze” plan at $810.84 per month to $2554.71 per month.  I didn’t bother to look up the $2554.71 one because if I had $2554.71 a month lying around, I’d buy a doctor.

$810.84 per month. $10,000 a year.  After taxes.  Where I live, you have to earn $15,000 to keep $10,000.

Not affordable.  Did I mention that?

The plans offered by New York State do not allow you to go “out of network” for healthcare.  In other words, you have to use a doctor in each private insurer’s list, or they don’t pay a cent of reimbursement.

Even worse, the plan “deductibles” — the amount you pay out of pocket each year before your insurer has to cover you for anything at all — are outrageously high.

Fidelis Care Bronze has a $3000/year deductible per person.  I’m in pretty good health; it’s a rare year I spend that much on doctors.  This is what used to be known as a catastrophic plan: OK if you get hit by a bus but useless for most people living typical lives.

After the $3000/year deductible, Fidelis would pay 50% of your bills. So if you rack up $5000/year in medical bills, you pay $4000 and they pay $1000. Crappy.

via Ted Rall’s Rallblog.

One good part of Obamacare was the expansion of Medicaid, the government health insurance program that serves poor people.  But because of a decision by the Roberts Supreme Court, conservative state governments are in a position to block implementation to those who need it most.

Medicare works.  It delivers health insurance for less overhead than for-profit plans.  If it were up to me, I would replace Obamacare with Medicare for everyone (a single-payer plan).  If that wasn’t feasible, I’d lower Medicare’s age limits year by year.

But one of President Obama’s stated goals is to cut spending on Medicare, as well as on Social Security.  The net result is leave patients even more at the mercy of the for-profit insurance industry.