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ObamaCare’s Relentless Creation of Second-Class Citizens

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By lambert strether of Corrente.

And we go to Happyville, instead of to Pain City. –Thomas Pynchon, Gravity’s Rainbow

One of the things I hate most about ObamaCare is the vicious and relentless way that it creates first- and second-class citizens. ObamaCare does this by construction, of course: ObamaCare’s central concept of eligibility — the outright denial that health care is a human right, but is instead just another pigfest of rental extraction — necessarily implies that those who are “eligible” and those who are not eligible are granted different levels of access to care. Here, however, I want to focus on three whimsical and arbitrary distinctions that ObamaCare draws between the worthy and the unworthy, the saved and the drowned, the lucky winners and the losers.

To begin, if you’re from Libby, MT, you’re a first-class citizen. If you’re from anywhere else, you’re a loser. I’m so sorry. Dr. Philip Caper in the Bangor Daily News:

After his own constituents in Libby, Mont., became uninsurable by private insurance due to industrial pollution with carcinogens and were unable to get the courts to hold the polluters responsible, [Senator Max] Baucus came to the rescue. He simply tucked a little provision into the massive health reform bill making affected Montanans eligible for — you guessed it — Medicare.

No health insurance exchanges for these hardworking folks. Nothing but the best for Libby. By taking the simple, direct and most efficient route to expanding health-care coverage, Mr. Baucus did the right thing by his constituents. But Baucus made sure that everybody else had to settle for Obamacare.

So whenever an Obot waxes lyrical on the glories of the Orwellianly named Affordable Care Act, just ask them how come the citizens of Libby, MT get to board the train to Happyville with a first-class health care system — single payer Medicare for All — and the rest of us losers have to settle for Pain City and ObamaCare.

Next, if you’re banked, you’re a first class citizen. But if you’re unbanked (or debanked), you could be out of luck. From Jackson-Hewitt:*

• More than one in four uninsured Americans eligible for the new premium assistance tax credits under the ACA does not have a checking account. Among the uninsured, non-elderly population with household incomes in the tax credit eligible range, 27 percent are effectively “unbanked.”

• Many insurance companies plan to require customers to pay premiums automatically through a checking account. While such restrictions may help insurers reduce administrative costs, unbanked customers will not be able to pay their required share of insurance premiums. Though contrary to the spirit and intent of the ACA, such restrictions are permissible under current federal guidance absent a policy clarification

• These restrictions will undermine efforts to expand health coverage under the ACA. Requiring enrollees to pay their premiums using a checking account would effectively deny coverage to the more than eight million unbanked Americans who are otherwise eligible for the new tax credits under the ACA. Unless addressed, such restrictions may hollow out the ACA’s expansion of coverage.

• The impact will be especially large among African Americans and Hispanic Americans, who are over 40 percent more likely to be unbanked relative to white residents in the same income category. This is particularly concerning given the existing disparities in access to health coverage and health status for minority groups. Further, as many as five million veterans and other Americans who receive federal benefits on prepaid debit cards may not be able use those same cards to pay their premiums for federally- subsidized insurance.

• The impact on the unbanked will be disproportionately large in states where the federal government operates a health insurance marketplace. Federal marketplaces will operate in 11 of the 12 states with the highest proportion of unbanked among those eligible for tax credits.

Sure, a wise and beneficent administration could fix this with a rule. But ObamaCare’s been around since 2009, and we’re only now getting around to this? Especially when the staggering genius minds behind the Obama campaign juggernaut now ensconced at Enroll America want to appeal to Hispanics? (Granted, they don’t have to appeal to blacks; “they have no place to go.”) Honestly, who the heck designed this thing? It’s like ObamaCare was written by some health insurance executive and then implemented by a gaggle of creative class technocrats, neither of whom have any understanding (if indeed they cared to have understanding) of ordinary people’s lives. Oh, wait….

Finally (for now), if you’re forced into Medicaid — and that means really being a loser, w-a-a-a-y more than buying a Bronze plan makes you a loser — you’re a second-class citizen because you might not be able to pass anything on to your kids, unlike the first-class citizens who are richer and whose kids are, therefore, more deserving of inherited wealth than your kids are. Counterpunch explains:

[I]f an Exchange determines you are eligible for Medicaid, you have no other choice. Code for Exchanges specifies, “an applicant is not eligible for advance payment of the premium tax credit (a subsidized plan) or cost-sharing reductions to the extent that he or she is eligible for other minimum essential coverage, including coverage under Medicaid and CHIP.” Therefore, you will be tossed into Medicaid unless there are specific rules as to why you would not be eligible. If you are enrolled in a private plan through an Exchange and have been receiving a tax credit, and your income decreases making you eligible for Medicaid, in you go. If you are allowed to opt out because you don’t want Medicaid, you will have to pay a penalty for being uninsured unless you can afford to purchase insurance in the open market. …

Furthermore, to increase enrollment in health coverage without requiring people to complete an application on their own, states are advised to automate enrollment whenever possible by using existing databases for social services programs such as SNAP (food stamps) to enroll people who appear eligible for Medicaid but are not currently enrolled. Therefore, you could find yourself auto-enrolled in Medicaid against your will if your state acts on this advice.

…. You won’t find the following info in the ACA. It’s in the Omnibus Reconciliation Act of 1993 (OBRA 1993) – a federal statute which applies to Medicaid, and, if you are enrolled in Medicaid, it will apply to you depending on your age.

a) OBRA 1993 requires all states that receive Medicaid funding to seek recovery from the estates of deceased individuals who used Medicaid benefits at age 55 or older. It allows recovery for any items or services under the state Medicaid plan going beyond nursing homes and other long-term care institutions. In fact, The Centers for Medicare & Medicaid Services (CMS) site says that states have the option of recovering payments for all Medicaid services provided. The Department of Health and Human Services (HHS) site says at state option, recovery can be pursued for any items covered by the Medicaid state plan. …

Your estate is what you own when you die – your home and what’s in it, other real estate you may own, your bank account, annuities and so on. And even if you have a will, your heirs are chopped liver. Low-income people often have only one major asset – the home in which they live and, in some cases, this has been the family home through several generations.

So what this boils down to is: If you are put into Medicaid – congratulations – you just got a mandated collateral loan if you use Medicaid benefits at age 55 or older! States keep a running tally.

So, Medicaid: Pain City (if not for you, then for your kids). Not Medicaid: Happyville! Your kids get the house! (Even accepting ObamaCare’s eligibility framework, which I do not, you would think that citizens would be given the choice between opting for Medicaid, and sacrificing their children, and opting for a really crappy plan that wouldn’t sacrifice their children. But n-o-o-o-o-o-o!!!!! They’re forced into Medicaid; that’s the issue here.)

So, if the rigged game chances and vicissitudes of life have left you a non-resident of Libby, MT, without a bank account, or simply poor, congratulations! You’re a second class citizen!

Lebensunwertes Leben, donchya know…

NOTE * Jackson-Hewitt is a tax preparer. It couldn’t have been more clear to me from my H&R Block experience this year that the tax preparers want a piece of the action from ObamaCare’s stream of rents. I mean, here’s the screaming headline on Jackson-Hewitt’s corporate site: “April 15 is Now the Most Important Day in Healthcare.” And it is! It is!) That said, this report seems to make some good points. And mainstream ObamaCare coverage, on all sides, is just as reliable as the talking points for Campaign 2014 and Campaign 2016 — which is, in fact what the ObamaCare rollout is. So what can you do?

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142 comments

  1. brian t

    I wish folks would stop calling it “ObamaCare”. The bill that eventually got through Congress was a political compromise that fell far short of the “single payer” plan he originally wanted. He has to support the result, of course, but he didn’t design it and his name shouldn’t be on it.

    1. Gerard Pierce

      Considering that Obamacre is likely to become a monstroust cluster-whatsis, Obama should get full credit for everyting that happens. It’s kind of a legacy thing.

      A breief question to any lawyers or financial planners out there: “Is there a way to use a family trust or similar mechanism to protect a family’s house against the ravages of Medicaid?

      Right now, there are a lot of people who need to quickly form such a trust – before the rules are cast in concrete.

        1. lucky

          Yes, it’s called MediCal planning in California. I believe the reason you need a lawyer to set it up is to avoid the look back.

          Warning, be VERY careful who you choose as trustee. Four years after my dad died, we are in court trying to get rid of a lawyer/trustee who has used the estate to take care of himself.

      1. TheWave

        Yes, I know other middle class families who have setup trusts. I don’t know the details but you should look into it. They went through a lawyer.

      2. sleepy

        Under medicaid, there’s a provision that certain transfers of property going back a certain period of time–5 years rings a bell–are counted in determining your eligibility.

        In other words, someone who owns a house valued at $100,000 and gives it to their children in 2013, then applies for medicaid in 2017 would still have that house value attributed to them in determing eligibility for medicaid–they wouldn’t be eligible and/or that house asset would still be subject to seizure by the state.

        But under Obamacare, with its mandatory medicaid based on income alone, I presume that the person would “qualify” but the state could still recoup its costs by using the 5 yr. rule and liening or seizing the property–whether the property was transferred to a trust or directly to your heirs.

        The smart senior would do a cash sale of their home, take the money and go to Vegas.

        Hey, you know what? I’m thinking that’s a new niche for some clever entrepreneur: quick cash sales of seniors’ homes (at a heavy discount of course). Even better if you can package and sell the cash flow as securities.

        You heard it here first.

        1. jake chase

          If you own the house free and clear, you might consider selling the house to your children in exchange for a private annuity the amount of which is based upon your life expectancy. If you rent the house back it reduces (and could even eliminate) the cash drain on them, and if the amounts chosen are fairly determined there will be nothing for Medicare to grab, because the house is no longer part of your estate, no gift has occurred and the annuity ceases at your death. Capital gains taxes are often not payable on the sale of a residence, and in any event most people who bought during the past eight or nine years have an impacted loss.

          Does this work? Similar strategies have been used for years by rich folks seeking to escape estate taxes. The real issue is whether you can trust your kids. And you should have a smart lawyer to touch all the bases, including the capital gains issue.

          1. Jimi

            Jake, You said “Their won’t be anything for Medicare to grab”
            Don’t you mean MEDICAID?

          2. Yves Smith

            You are way behind the state of the art.

            My great uncle had to sell his house to qualify, this at least 20 years ago. And no way would a sale to a relative have been permissible.

      3. Pokey

        Does it strike anyone else as a little incongruous that we cpmplain about insufficient resources devoted to medical care for the poor and devise schemes to obstruct one of the mechanisms intended to delay insolvency of the system?

        From a social standpoint, I cannot think of any good reason why people should shift the cost of care for their elderly to taxpayers so that they can cash in on Moma’s house. This is particularly galling when the subject comes up in the barber shop after some teabag diatribe about the evils of gov’ment.

        1. katiebird

          Because if you make enough money to squeeze into the Exchange Buckets then taxpayers will subsidize your premiums with cash payments sent directly to health insurance companies.

          But, if you DON’T make enough money (possibly for even a part of a year) then you or your family will have to cough up the dough (eventually) (if you have any assets at all) to pay back any health care assistance you’ve needed.

          Why should the POOREST of us be required to liquidate what little assets there are in the family while everyone else gets a (comparably) free ride?

        2. Gerard Pierce

          “Does it strike anyone else as a little incongruous that we cpmplain about insufficient resources devoted to medical care for the poor and devise schemes to obstruct one of the mechanisms intended to delay insolvency of the system?”

          In the real world, there are a number of poor familes where the house has been passed down thru several generations. In these families, this house may be the only family asset and the loss of this house could impoverish a number of people. The fact that title to the house is vested in one elderly person does not reflect how it works in the real world.

          Delaying the insolvency of the system is not sufficient excuse for throwing these people under the bus – especially when what they get back is US medical care.

          1. Pokey

            We are not talking about the crappy delivery of medical care, but rather long term (the average nursing home stay was once about 22 months) care.

            I would be happy if we collectively recognized a responsibility to care for disabled elderly as a direct government service — in a government owned facility. The long term care industry is just like the insurance industry. The setup is for the owners to suck the blood out while we all pay tribute to their capital.

            Unfortunately, there do not seem to be a lot of viable socialist candidates out there, at least not here in Louisiana. In the meantime, I object to people who don’t want to pay taxes foisting the expense of their old on me. Their parents should have the decency to die so that their freeloading offspring can have the house and more beer while watching football.

        3. jake chase

          The issue quite simply is whether you wish to inhabit the United States of Mexico. If the answer is no you should favor any strategy that allows poor and even middle class people to keep whatever assets they have managed to accumulate despite having everything stacked against them.

          1. jake chase

            As Jimi points out, my reference to ‘Medicare’ in the previous thread should have read ‘Medicaid’.

          2. Jimi

            Jake, Thanks for clarifying that. I was about to look it up myself but your original post gave me a cardio infarction and only now has it subsided. I’m better now!

      1. petridish

        +1000. I’d go so far as to say that achieving this was the reason he was given the job.

      2. washunate

        I’m really hoping it’s sarcasm. Otherwise it’s about the most hilarious unintentional humor you will ever read.

    2. scott

      If Dems want to clean house ins 2014 they should run on repealng Obamacare and replacing it with single payer. Intersting that the liberals are just now realizing what Obamacare is…a last ditch effort for the insurance/pharma cartel to extract a few trillion from a system that was going to implode anyway. They know 10 years ago that the current system would die, so they (insurers) wrote the legislation and waited for a president that would abdicate his responsibility and let the legislative branch bend enough rules to pass this monstrosity.

      1. Chris Engel

        Why not just have a Medicare-for-all public option and have the government subsidy cover it completely, thus leaving no gap or dependence upon a private policy?

        I think all people want is to be able to have an affordable public option that keeps the private insurance market honest and legitimately ENDS medical bankruptcies.

        1. lucky

          Insurance providers objected saying that it was unfair competition because government could provide coverage cheaper.

          “Republicans on the committee unanimously opposed the public option, saying it was, in the words of Senator Orrin G. Hatch of Utah, “a Trojan horse for a single-payer system” in which the government would eventually control most health care.”

          http://www.nytimes.com/2009/09/30/health/policy/30health.html?_r=0

          1. Chris Engel

            I’m aware of the history, but was responding to a normative suggestion for policy.

            The insurance market is so very shady. A public option would keep them honest (and it would still be profitable). There are numerous ways for us to avoid medical bankruptcies, by insuring against them (it’s tail-end long-term illnesses and elderly care that are the most costly in any healthcare system).

            If we conducted policy by only caring about the short-term effects on big powerful industries like insurance, we’d never have built the automobile or paved highways for fear of affecting the railroad trusts.

            The idea of having different tiers of plans where those who can’t afford a certain quality of coverage don’t get it — it just doesn’t make sense. The insurance corporations can divest from the healthcare insurance hustle and focus on dental or other crap.

            All I know is that nobody who is insured should ever have to deal with ridiculous bills and be forced into bankruptcy. Offering different “tiers” of plans is an implicit admission that those “bronze” who are going to be uninsured are still going to be stuck with stupid deductibles or god knows what stupid costs involved to get the care needed.

        2. Lambert Strether Post author

          @Chris Engel Please, not the public option zombie magic sparkle pony again. The so-called public option was a bullet point from an academic policy entrepreneur; it was never a serious policy proposal. It was, in fact, bait and switch operation operated by career “progressives” running interference for Obama, designed to suck all the oxygen away from single payer Medicare for All — which it did, very successfully.

          The cream of the jest is that Obama sold the so-called public option down the river to Big Pharma, and, if he told the “progressives” about that, they didn’t tell anybody else; and those same progressives had marketed themselves as the savvy, non-purist, “don’t let the best be the enemy of the good” types. Whether these guys were in on the scam, or played by Obama, I don’t really care; it’s just another case of stupid and/or evil.

          Bottom line is that public option advocacy was a long and not particularly savory history. Of course, if ObamaCare does tank, I would expect the progressives to get the ol’ magic sparkle pony up on its zombie hind legs once more

      1. Lambert Strether Post author

        That was in 2003, IIRC. Obama had no “skin in the game” at that point, so he said what he had to say. Then when he got skin in the game, he said what he had to say again, even though it was different. Shocking, I know.

    3. banger

      Single payer was never a goal of Obama–he had little interest in that or any of the alternative systems used around the world. First he wanted to cater to the insurance industry and that ended any hope for real reform.

      Had someone in power been truly for a sane system (there are many systems out there that are not single-payer) I think the public would have supported it. Instead the media and politicians did not include sanity, science or reason into the “debate” on health-care but, rather, deliberately manipulated the situtaion into a pro-wrestling bout where the outcome was the hodge-podge of confusing and contradictory band-aids that does nothing to uncomplicate the system.

      1. Lambert Strether Post author

        Yes, there are many plans out there. I’m so fierce on single payer because (paradoxically) I’m a pragmatist. We have a single payer program in this country called Medicare*, and we have a single payer program on this very same continent in a very similar culture that’s even called Medicare: In Canada.

        We don’t have to run this huge and massively unethical medical experiment on the health of the American people to find out how to “bend the cost curve.” All we have to do is look at the cost curves for the US and Canada. Before single payer, both curves rise at the same rate. After single payer in Canada, their rate of increase is far less than ours.

        If indeed the object of health care reform was saving money and — heck, why be more cynical than I have to — human lives, then the obvious thing to so is look at a system that meets those requirements, and adopt it. That wasn’t done, ergo, ObamaCare had a different set of requirements.

        NOTE * I should say that Medicare is also a terrible example of first and second class citizenship: What is so special about elders that they and they alone get what should be a basic human right that comes with your birth certificate?!

        1. banger

          FYI the federal gov’t essentially pays for half of our system right now–a bit more and we’d have the Canadian system.

    4. Kokuanani

      “Obama wanted single payer” — please, do you still believe in the Easter Bunny, Santa and the tooth fairy?

      Obama dealt away single payer in his first meetings with the drug companies and insurance mavens. Then he pretended that he wanted it but couldn’t get it.

      All these years of Obama’s phony “I just couldn’t get it done, the other guys were too strong” and you haven’t caught on to his ploy?

    5. Doug Terpstra

      Brian, consider yourself schooled. Obama is not the reluctant, thwarted messiah he pretends to be. His empathetic persona is but a masterful fabrication.

      Banger and Engel nailed it. As Engel notes, Medicare for all was the glaringly obvious, proven solution to the tragedy of profiteering on immiseration. As a clear moral imperative, here was an epic gift to anyone with a pulpit, yet Obama, the vaunted orator, studiously avoided it. Worse, while lobbyist were flocking to the white house and Congress, Obama repeatedly, pointedly spurned meeting with Doctors for Single Payer. And as Medicare itself went under the knife, he remained conspicuously, deafeningly silent. He recently offered to cut it again in the quest for austerity.

      His muteness was starkly silhouetted by tea bagger signs shouting, “Keep your government hands off my Medicare”, revealing the easy sale Obama could have made with even a token effort. (It was the same with Palin’s government “death panels”; what pray tell are insurance company gatekeepers?). The farcical charade of Obamacare “negotiation” was the inflection point for me, when deep disappointment in Obama turned into involuntary contempt. That has only grown worse.

      1. banger

        Obama was the candidate of the corporate oligarchs from the beginning–everything now is show biz and Obama is all theater or I should say all Mad Ave.

        But the problem was not so much Obama but the mainstream media that flat-out refused to cover the issue except to act either as propaganda organs for the oligarchs or just cover it as a horse-race. One of the reason the press is so stuck on celebrities, horse-race and all that stuff is that that way they get to avoid doing their jobs–they know that if they actually covered the news that they would have to lie like hell to keep their jobs. Any bit of truth in the mainstream sends alarm bells ringing all over the country and eveyone jumps on the heretics tout suite.

        There were a few think pieces here and there that touched briefly on reality but for the most part the entire “debate” was completely theater. The left is also to blame here for not forcing the issue and not supporting those few people in Congress who fought the good fight. This issue was the most critical issue of the Obama administration from a political POV. When Obama and his little weasel friends at DKOS saw how easy the progressive folded on this issue he knew he could run anything past them including austerity. Obama has been far more fatal to the left than any right-wing President.

    6. nonclassical

      ..as Lambert has pointed out several posts, bushbama proved by whom he appointed to “investigative commission” he had no intention of his own proposed “public option”, which also as Lambert has pointed out, was intentionally imposed RATHER THAN any discussion of full healthcare for all…
      co-opting dems over to “public option”…away from full healthcare provision..

      Those of us who have lived in countries WITH full healthcare (my wife is nurse in Germany) can speak lucidly to reality of full healthcare for all…

    7. Binky Bear

      Fanciful or naive?

      To get the lucrative former president payoff he certainly chose the correct path. Shoving Romney’s own health care initiative down his throat must have been satisfying and rewarding. Guaranteed rents for the lives of 330,000,000 Americans with government punishment for people not buying a product, with a cut for the guy who made it happen?

      Single payer? Did Obama ever once say that even as a joke?

    8. REDPILLED

      Obama never seriously “wanted” single-payer health care! He took it off the table early on, then even removed the public option. The individual mandate in Obama’s ACA is from the conservative Heritage Foundation’s plans of years ago, so ACA is hardly a “liberal” plan. Obama had majorities in the House & Senate in January, 2009, and pressure on Harry Reid to reform the filibuster would have made passage of a truly universal health care act possible, but Obama declined to use these majorities. As with his economic advisors, all Wall Streeters, his health care proposal aids health insurance corporations more than citizens. Obama’s continued bank bailouts and refusals to prosecute Wall Street fraudsters are merely further confirmations of his loyalty to Wall Street and corporations and betrayal of citizens.

    9. Pelham

      I may be wrong, but I don’t believe Obama at any point ever advocated a single-payer plan. His plan on the campaign trail in 2008 was for a number of options, including a public option, with no mandate.

      Then, after he was elected, he quickly and unilaterally dropped the public option before even entering talks with Republicans and opted for the mandate — something that he adamantly opposed and used to beat up Hillary Clinton for advocating during the 2008 primaries.

      It was a classic bait-and-switch.

    10. DolleyMadison

      It is becoming increasing tiresome to hear Obama apologists claim after each stinging betrayal that Obama’s hands are clean (and tied) – as if he is some infant King oblivious to the running of the kingdom. If Obama “didn’t know” what was in Obamacare, or the Foreclosure “settlements” or IRS targeting, AP surveilance, CISPA, SOPA, the Patriot Act, QE3 etc. – it was because he chose NOT to. He could not be any less concerned about sick people, or bank victims, or freedom of the press or whether or not our country survives. He is interested in getting richer than Midas, and we can all go Eff ourselves.

    11. Climacus

      Quoting the man himself: “You want to call it Obamacare — that’s okay, because I do care.”

    12. Ames Gilbert

      I don’t think we are talking about the same Obama.
      The one I know of talked big about Single Payer during his run for Chief Puppet, just as he talked big about ‘the most transparent administration ever’, ending illegal wars, supporting whistleblowers, ending illegal wiretapping, and on and on.
      That’s the same Obama who started ‘negotiations’ about health reform with the precondition that “Single Player is off the table”, and then proceeded buy health care industry support by letting them write the legislation.

    13. Peter

      ” … the ‘single payer’ plan [Obama] originally wanted”?

      Obama who refused to meet with PNHP? Who disinvited his pro-single-payer personal physician from Chicago from appearing on the ABC healthcare reform special? I think you meant:

      ” … the ‘single payer’ plan [Obama] originally *pretended to want*” in order to win the primaries.

      Watch the PBS Frontline documentary “Obama’s Deal,” or read John Geyman’s “Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform,” and then tell me how committed Obama was to single-payer.

    14. Nick

      He signed it. He owns it. This train wreck made it through Congress without any Repubulican support. So Obama and the Democrats will get all the credit/blame.
      Regardless, you might end up getting what you want. I predict a bailout of private healthcare insurance providers within 5 years. They will be losing money and their shareholders will demand they get out of the healthcare business altogether. The program, as designed by the Democrats, was designed to fail. As Rahm said all those years ago, “Never let a good crisis go to waste.” A crisis it will be. With the young & healthy paying the $95 penalty not to be covered and the old & sick with pre-existing conditions assuming coverage at well below market rates, the whole thing will collapse. The government will step in at that point declaring a (self made) crisis, and the only “cure” will be a government single payer system. Then get ready for rationing and all the problems with filthy hospitals and uncaring doctors & nurses as you have in the UK. With government invovlement and health care rationing, illnesses will become “political.” Breast cancer will be more important than heart disease, etc. THe “1%” will float above it, going to private offshore clinics and hospitals that will surely be set up by the best and brightest doctors that will flle the country and government salaries. They will be replaced by doctors from and educated in the 3rd world.

      1. diane

        Love much of that comment, but really, re breast cancer, in the U$????????

        that recent Jolie moment (which did not at all address the real issues there), has now been replaced with Mikey’s warnings about getting throat cancer from those diseased females.

        (Breast cancer might seriously be addressed in the U$ at such a time when females didn’t make far less than a male’s dollar (still) and didn’t represent the predominant majority of those uninsured or underinsured. Particularly in the ‘black’ community, where so many females are stunningly cut short from life continuance, at such young ages, via triple negative breast cancer)

        As to gawdawful U$ hospitals, they’ve been here for quite a while, for the ‘middle class’ and the historically and recently indigent.

        Not to say at all that I’m defending brian t’s inexplicable, yet unmistakable whimper on the behalf of that $ociopath, Obomber.

        1. diane

          I dare say that in the UK it is likely the same, as regards breast cancer. I worked, in San Francisco (for a brief highly educational ‘moment’ in my life), for an ancient, ghastly UK AG[ricultural Monster] entity, which emanated from the sugar cane trading days ….their mysogyny was stunning in the face of that ghastly tea sipping gentile ‘gentle mannly’ shit, even far worse than the Brit, London Corp. petri dish, the U$.

          1. diane

            (and no one really wants to know about the underbelly of that one, … the AG Industry , and its toxic, “$pinal Ganglia” (as highly venomous Veneman (was that her surname? I think it’s close) put that ‘ground beef product’ term, in 2002 (or was it 2003?))).

  2. Chris Engel

    Is anyone else tired of hearing Obama, the Democrats, and “progressive” organizations using the talking point of ending medical bankruptcies to push Obamacare?

    I was watching Bill Maher’s show on Friday and this horrible woman Neera Tanden who is propaganda minister (or something like that) for Center for American Progress had this to say:

    TANDEN: Yes. I helped write the bill. So yes, I read the bill. I read all 2,200 pages of the bill. And you know like Dodd-Frank and the immigration bill? These are all long bills. The number of pages don’t matter to how complicated it is. There’s been a lot of rhetoric for years. When you have people who can afford healthcare for the first time. When we have a country where you no longer have to go bankrupt because of your healthcare costs.
    (HBO’s Real Time, May 31, 2013)

    Two points here:

    1) If you’re a progressive, why would you brag about having anything to do with Romneycare, err, I mean Heritagecare, err, I mean, Obamacare? Let alone WRITING the shitty bill.

    2) Why is she trying to connect Obamacare to “no longer having to go bankrupt because of your healthcare costs”? Obamacare will solve one problem of uninsured America and create a new epidemic of underinsured America. Most bankruptcies for medical bill reasons are by people who HAVE HEALTH INSURANCE! ( http://www.businessweek.com/bwdaily/dnflash/content/jun2009/db2009064_666715.htm ) The minimum standards set forth for insurance under Obamacare are not sufficient to stave off medical bankruptcies at all. You’re better off on Medicaid than being underinsured…

    There should be disincentives to lie like that in a policy discussion being absorbed by the public. The most offensive part was that the crowd was howling after she made that statement. They didn’t even realize that it was a complete lie and that Obamacare will do virtually nothing to stop medical-bill-driven bankruptcies.

    1. spooz

      I had to turn the show off before the end when Tanden’s obsequious laughter at everything coming out of Maher’s mouth got to be too much. I was upset enough about the ignorance there to seek out a place to comment on HBO, actually posted a Nakedcapitalism link on this forum:

      http://www.hbo.com/real-time-with-bill-maher/index.html#/real-time-with-bill-maher/talk/forums/item.html/eNpNjcsKwjAQACmFgn7FXkQ8FJpobQ14kHoWf2FtVruYNtikPo7+uc2h4GlgDjPzKm5iGz9WT9ZkDx2aj+e6sp2nt19aoyd1xhudsKVZFCU4sN5f8qLMhdgs5LHGQo4QggJKcaURWSal2G11KYmSKPmuHfVMTkFPaMBzS-Bi38CFjYEWG+oVeDR3BZpdPTjHtlMwXdLwSMMhDf30v-4DKOU61A==

    2. run75441

      Chris:

      While there are faults to the PPACA as designed by Congress and you could go bankrupt, the most you will pay out of pocket is ~$12,000 which is far less than what it used to be. That is, if you are covered by the PPACA or other means. With many states not expanding Medicaid to 138%, many not even covering up to 100%, and many adults being single; there is another gap which people below 100% of FPL not being eligible for PPACA subsidies.

      1. petridish

        So Neera, er I mean run75441, could you please explain where the “~$12,000″ comes from and how that is “far less than it used to be?”

        While you’re at it, please explain how going bankrupt for only $12,000 is better than going bankrupt for $1,000,000.

      2. Yves Smith

        Don’t even try that lie here.

        ObamaCare preserves the fraud out. If someone has defrauded a medical insurer, he can refuse to pay claims.

        Oh, and what is fraud? It includes NOT TELLING YOUR INSURER ABOUT A PRE-EXISTING CONDITION. It can be really trivial, like you had acne in your teens.

        Insurers now routinely go after people who have big insurance bills to see if they can get them on fraud. One expert estimated (based on the gross # of denials, which sounds small until you compare it to the # of over $100,000 cliams) that as many as half the big claims may be being denied NOW due to alleged fraud.

        And with a lot of new people enrolling, it’s going to be even easier to get people on that (it’s hard to do that to someone like me who has been with my insurer for nearly 30 years….I pretty much have no prior history at this point).

    3. banger

      Who knows what it will do? Lobbyists wrote the bill and it remains to be seen what trucks armies of lawyers will drive through loopholes written into the bill–I never liked it and it should not have passed because it was written under false assumptions due to a disinformation campaign mounted by the mainstream media.

      The American people know nothing about the issue of health-care in this country and what systems around the world actually do–they don’t even know that most of them are not single-payer. Just like virtually no Americans know (unless austerity has changed it) that many Euro-countries get 6-weeks paid vacation whether they are big shots or small fry. Virtually no one knows about pro-family legislation in other countries and this is deliberately kept from the public by the mainstream media which operates only as propaganda organs for various cliques within the oligarchy.

      1. nonclassical

        ….yes, and ameriKans know nothing about international education=fully educated workforce, through university or vocational equivalent for FREE, creating lifetime taxpayers, rather than winner-loser-majority mediocrity, “cheap labor force” priority either..

    4. washunate

      Yes. One of my pet peeves is when someone identifies a problem and pronounces it to be important and then advocates responses that do not solve the problem they just themselves said was so important to solve.

      It’s a simple, easy way to tell whether someone is operating in good faith or attempting to deceive.

    5. Lambert Strether Post author

      Yes. RomneyCare (the model for ObamaCare) did not significantly reduced medical bankruptcy (PNHP):

      Medical bankruptcy in Massachusetts still accounts for about half of all bankruptcies. That was true before the 2006 legislation went into effect and that was true after 2009, after the legislation had been around for a couple of years.

      It’s pretty clear that what was done in Massachusetts didn’t impact the problem of medical bankruptcy in any significant way. And if you look at what the insurance is like in Massachusetts, it’s pretty similar to what will occur under Obamacare, that is, very high copayments and deductibles.

      1. Chris Engel

        Someone ought to page Obama and his lobbyist cheerleaders to update their talking points and stop lying by saying that Obamacare will do a damn thing about medical bankruptcies.

    6. washunate

      Too many facts Chris!

      I’ve disagreed with you elsewhere so just wanted to say you are spot on here. The main problem is not the predator class per se; it is the selling out of the liberal class. The lack of opposition from people who know better is why we’re at where we’re at.

      I will be eternally grateful to Jane Hamsher’s brilliantly simple, and wonderfully antagonizing, veal pen imagery.

  3. George Hier

    Not that I wish to let politicians off the hook, but a modicum of research (i.e. following the links 3 citations deep), reveals that the Libby, Montana Medicare thing is a bit less broad than it might seem:
    From the Social Security Administration website’s page on Libby, Montana itself:
    To receive this Medicare coverage, you must have been:
    Diagnosed with an asbestos-related disease; and Present in Lincoln County, Montana for a total of at least six months during a period ending 10 years or more before the diagnosis.

    Hrm. Not so much “Medicare-for-All”, so much as it is just your standard-fare district pork. Just gracious enough to the plebes to help your re-election/burnish your legacy, but not enough to actually offend any of your corporate sponsors.

    1. Lambert Strether Post author

      Good catch; I will tune my rhetoric. That said, it’s still Baucus giving his constituents something all should have as a basic human right.

  4. Jim Haygood

    ‘Requiring enrollees to pay their premiums using a checking account would effectively deny coverage to the more than eight million unbanked Americans … [and] hollow out the ACA’s expansion of coverage.’

    Great! To kill Obamacare, its alleged objective of broadening coverage needs to fail. In 2014, families who don’t have eligible insurance will pay $95 per adult and $47.50 per child, with the total amount for each family capped at $285 or 1% of income above the filing threshold.

    For a healthy adult, the penalty of $95 likely would be less than the monthly premium in a plan offered through an exchange. Therefore, there’s a strong incentive for those who don’t need coverage to shun it, and an equal incentive for those with pre-existing conditions to sign up.

    By systematically loading down exchange-offered plans with the sickest patients while the healthy stay away, an ugly cost spiral will ensue, forcing more people to drop out. Soon enough, the debacle of Obamacare collapses under its own weight.

    Young adults who are already indentured slaves to student loans don’t need another cash suck. Shun Obamacare, pay the wrist-slap penalty, monkeywrench the politicians. Then watch Obamacare trip on a root, slam its hydroencephalitic head on a rock, and die young.

    1. washunate

      Right on. Healthcare policy is very simple. Do we want a social contract where younger, healthier, and wealthier people subsidize older, sicker, and poorer people, or not?

      1. Lambert Strether Post author

        That’s not how I’d frame it, because the categories of people doing the subsidizing are not static but dynamic. It’s not really “the well” subsidizing “the sick” because you may feel well today and in fact already be sick.

        I’d prefer the moral basis of “There but for the grace of God go I” (for some definition of “God”). On that basis, guarantee health care to all as a matter of right — which, I might add, ObamaCare does not do, and Obama does not advocate (modulo the quote from 2003).

        1. washunate

          I understand what you are saying, and I agree basic healthcare is a human right.

          But you have an underlying premise (of which you may not even be aware) that is just flat out wrong.

          Healthcare costs are not randomly distributed. There is a great deal of predictability and choice. Any enduring social contract requires dealing with those variables, not ignoring them.

          1. washunate

            Yeah, I’m not sure what framing works best for you. Perhaps it’s the difference between the investment part of healthcare and the consumption part of healthcare, or the mathematical concept of correlation, or the insurance concept of risk pooling, or the ambiguities inherent in beginning and ending of life issues.

            But however described, there is a huge amount of choice in healthcare decision-making that involves allocation of scarce resources, from neonatal intensive care to vegetative states on life support. The ‘public commons’ stuff like clean water and clean air and sanitation and hygiene and food inspections and immunizations and antibiotics are what allowed the massive improvements in public health in the 20th century, but that’s not where most of our expenses in contemporary medicine go.

            Much of the costs are consumed by far extreme outliers of drugs and hospital stays and nursing home care – ‘treatment’ as opposed to ‘prevention’ that primarily is for private gain rather than public good, and for which people can make choices (for example, advance directives). There is no technical answer about where to draw the line between public good and private benefit – that has to be actively dealt with through social norms. To claim that it requires no transfer of wealth from people who desire less care to people who desire more care is to deny the basic economics of the situation. This is where the whole death penal ridiculousness comes from – preventing death has become exponentially more expensive for each little bit more we develop. We’ve done the cost-effective stuff fighting disease and infection and pollution and so forth; now we are directly taking on evolutionary forces themselves.

            http://www.nlm.nih.gov/medlineplus/advancedirectives.html

  5. petridish

    Some big-picture questions:

    How long before medical debt goes the way of student loan debt and becomes nondischargeable in bankruptcy?

    Is the failure to have medical insurance due to the failure to have a bank account two offenses or one?

    Don’t we still have this debt crisis going on? What happens if, due to budget constraints, the feds fail to make subsidy payments to the insurance company on my behalf? Is my policy cancelled? Do I get a refund of my portion of the premium? Am I responsible for full payment for any services I received while under the illusion that I had medical insurance?

  6. LAS

    There’s a lot we do not know. However, I believe that Obamacare (ACA) does slow the total collapse of the healthcare system which is on an unsustainable trajectory. In that sense it is a temporary improvement. Has it solved all our concerns? Certainly not.

    There are some people who want the total collapse. I don’t wish it. So many more innocent people will suffer adverse outcomes that way.

    The political climate and class divides in this country are truly the culprits, sewing discord and destroying the power of a united people to demand single payer funding of universal healthcare with utility-like regulation of common procedures and drugs.

    1. banger

      I don’t believe the medical system would have collapsed without the ACA. The ACA is an unreasonable bill that rewards those who cause the greatest damage. At best it is, as you say, a kind of band-aid, a bit of duct tape here and there but the overall plan is, as I said, fundamentally irrational.

      There are dozens of great systems around the world (compared to ours) and we refused to even consider them. Alternative systems other that single-payer (a minority of systems have single-payer) were not even discussed by the politicians or the media. People who study the problems were ignored and political flacks were left to write the bill so that it pleased enough lobbyists to squeak by the ACA. We had an opportuinty and we blew it–but at least a few of us realized that Obama was for real, i.e., a tool of the FIRE sector created to deceive and defang the left.

  7. washunate

    Keep ‘em coming Lambert. What fascinated me about the healthcare debate 4-5 years ago among liberals was that a lot of people chimed in with claims that were obviously not based on the actual mechanics of how things work.

    It’s like saying that the way to win a tennis match is for a baseball player to throw a touchdown pass, or the way to write a good high school essay on 1984 is to regurgitate Cliff Notes from Hamlet.

    1. Lambert Strether Post author

      It will be the same now. In Obama’s presser, he said “We will implement it.” So the marching orders are out. That presser was the opening gun of Campaign 2014 and 2016, too.

      And that means that you should filter every single statement about ObamaCare from any Obama-supporting pundit (Krugman, DeLong) and all Democrats just as if you were filtering statements in a Presidential campaign where “He has to say that” is the rule. IOW, given them no credence at all.

  8. Arrested Baucus

    The poor and disheveled should be allowed to apply for a reduction in medical bill principle. We can’t let the proles escape into financial ruin more than once every 7 years. Therefore, a program to assist the creditors needs to be crafted, modeled after the highly successful HAMP initiative.
    Paystubs, tax returns and most importantly, a hardship letter explaining why they got cancer, a careful calculation to determine whether they “are good for it”, then a modest reduction in principle or interest rate over more years, until death by natural causes.

  9. Jim Haygood

    One of the great conceits of Obamacare is that it was drafted and passed by people in Washington who narcissistically assume that everyone else is like them: literate, well-informed policy wonks with stable jobs and residency.

    The people they’re trying to reach ain’t like that: they aren’t well-informed about policy; they pay someone else to prepare their taxes; they have gaps between spells of employment; and above all, they don’t have much discretionary income.

    A survey released today fills in some details:

    There’s no assurance folks will be buying insurance under Obamacare, and that could spell trouble for the Affordable Care Act.

    Nearly two-thirds of Americans who currently lack health insurance don’t know yet if they will purchase that coverage by the Jan. 1 deadline set by the ACA, a new survey revealed Monday.

    And a whopping 68 percent of low-income Americans aren’t sure they qualify for tax credits that would subsidize their purchase of health insurance. 64 percent [of uninsured adults] said they haven’t decided if they will purchase insurance by the Jan. 1 deadline.

    Public uncertainty about Obamacare—particularly a lack of commitment to signing up—could end up driving up health-insurance costs under the program because not enough healthy people will participate to offset benefits payouts.

    http://www.cnbc.com/id/100783056

    For people whose income fluctuates (proprietors, salespeople, consultants, part-timers), or who take time off to care for a family member, or who move from state to state in search of work, the concept of ‘qualification’ is simply unworkable. This month you qualify, next month you don’t. And the paperwork …

    In normal countries with publicly subsidized care, you simply make an appointment and show up. Since private care is generally costlier, qualification is self-sorting: if patients could afford private care, they wouldn’t be waiting in line at a public clinic.

    Having no concept of how the other half lives, Washington’s well-heeled, Ivy League policy wonks have designed themselves an epic trainwreck that Joe Sixpack don’t like and don’t understand. Let it bleed!

    1. washunate

      Agreed, except I think that is way too friendly to the leadership in Washington. This isn’t about good faith mistakes. The Obama campaign and Administration knew exactly what they were doing. That’s why PR manipulation and secrecy were central to the process.

      1. Jim Haygood

        ‘Too friendly to Washington’ — my apologies; gotta buff up my militancy.

        Meanwhile, a bit of comic relief. All fifty state health exchanges are supposed to open for biz on October 1st. How’s that working out?

        The federal Healthcare.gov site lists eighteen states which have established prototype health coverage exchange sites. Seven other states are ‘partners with HHS.’ No links are provided to their sites.

        And the other 25 states? Presumably they are wards of HHS too. Four months before the grand opening date, HHS doesn’t have any prototype state exchanges online.

        http://www.healthcare.gov/marketplace/about/state-marketplace/index.html

        Unlike say Amazon.com, who needs your business and tries to make shopping easy, Obamacare is based on naked coercion. So the customer interface is likely to resemble the DMV — that is, have your papers in order, read the [complex] instructions, fill out the forms … or you’ll have to come back tomorrow and start all over [stoopid].

        1. washunate

          “my apologies; gotta buff up my militancy”

          Excellent, Overton window moved :)

          But in all seriousness, it is fun to laugh at the exchanges. It’s like, does no one in power understand that any of us muppets can go to ehealthinsurance.com and browse guesstimate rates and coverages? What’s the government going to do, have Suze Orman peddling the improvements?

          Oh wait…

          http://www.oprah.com/omagazine/Suze-Ormans-Twelve-Steps-to-Wealth-Step-8

          The biggest mistake Obama made was saying the Exchanges would be up and running this fall. The key to successful predictions is to not put a date on it; every two bit snake oil salesman knows that!

          When they’re not (or worse, when they’re cobbled together like so many beta releases not ready for prime time), it’s going to be a disaster. Hilarious and predictable, but still quite sad thinking about what people who desperately need this to work are going to encounter (from tech problems to legal minefields). In the employer HR world, the consensus is gelling pretty solidly now that the obvious solution is to not cover any currently uncovered workers in categories that allow a distinction from your core full time staff (like temp workers). Any fines the government imposes will be less than assuming that risk yourself where one cancer treatment, premature baby, or organ transplant can wipe you out (either through direct liability due to self insuring or clerical errors – like paying a bill late and having the policy cancelled – or indirectly, through renewal rates skyrocketing).

          But hey, maybe this is actually all PR for the DMV. Those are much more customer friendly operations than junk insurance. I mean quality affordable healthcare. After all, it will be here in four months. Baseball playoffs and free Cerezyme, here we come!

      2. banger

        As a veteran of Washington I can tell you that the government is driven by PR the same way that Microsoft was always driven by marketing except much more so. Propaganda, spin, is the entire game for every pol and for every department and agency. Sure there are some good people but they are all self-deluded or cynical and easily seduced and/or threatened.

      1. John F. Opie

        Hi -

        If there’s any proof needed that this is indeed a pigfest of rent-seeking (a wonderfully turned phrase, by the way), it’s the involvement of the IRS as the enforcer and inquisitor. The IRS already knows how much you earn and what your deductions are: the playing field is tilted in only one direction at this point. It’s the perfect tool for rent-seekers who want to help themselves to your available income.

        This kind of rent-seeking is mirrored in tuition: you, as the parent of a kid heading to college, have to tell colleges what you earn via FAFSA (and you can’t avoid telling them by declining FAFSA, as it is usually part of the application process that is required), giving universities and their finance departments all the benefits of knowing how far they can raise tuition without regard to actual costs.

        Of course, when you add up all those seeking to maximize their profits by requiring the purchase of their services by consumers, you quickly exhaust the consumer’s funds and push them into what I call virtual poverty (i.e. you earn a decent living, but everything you earn isn’t yours any more).

        A pigfest of rent-seeking indeed.

  10. Ms G

    The outright deceptions of ObamaCare just keep leaching out. Here’s a doozy: whereas the thresshold for claiming a medical expenses deduction used to be 7.5% of Adjusted Gross Income, Obamacare raised the level to 10%, for an effective tax increase on middle class (mostly self-insured) people, one of the slivers of the population that Obamacare supposedly “rescues” with the Loser-to-Elite Exchange Insurance Products.

    How’s that for “giving” with one hand and taking with the other. Just another little surprise from Obama the Great Deceiver. Enjoy, “folks”!

    1. Jim Haygood

      You’ll love this one … from New York’s health exchange RFP, page 11:

      Navigators/In-Person Assistors. Consistent with the federal law, the DOH provides grants to qualified organizations to act as Navigators and In-Person Assistors for the Exchange. Navigators and In-Person Assistors will provide in-person, linguistically and culturally appropriate assistance to those applying for coverage through the Individual Exchange and/or SHOP Exchange. Health Insurer Applicants must cooperate with Navigators and In-Person Assistors that have contracts with the Exchange.

      https://www.statereforum.org/sites/default/files/ny_invitation_to_participate.pdf

      In Latin America, these folks are called gestoras. They’ll prolly be called gestoras in Nueva York, too.

      They know that health coverage exchanges are going to be difficult for the majority of americanos who are allergic to slogging through thick gobbledygook, and virtually incomprehensible to non-native speakers.

      On the bright side: JOBS! Good, unionized jobs (at least in Nueva York) for gestoras. Obviously these new jobs will greatly enhance U.S. productivity and living standards. /sarc

      1. Ms G

        Ya, the Navigator jobs program is hilarious. Elsewhere Obama P.R. has revealed that “qualified organizations” means nonprofit community outreach outfits that typically work with “special” populations. You tell me how these people are going to understand ObamaCare any better than the few of us who are paying attention and getting huge headaches — or how their community outreach skills qualify them to do what we’ve been doing and then to hit a home run by understanding ObamaCare sufficiently to *accurately* explain it to “people.”

        Navigators sound to me like a walking-around-money (for Obama-party base) type of jobs program. Very little to do — on the surface, even — with “guiding” anyone to make an informed choice about whether to even buy a crap Exchange Product. I’m predicting “outreach programs” that include lots of free stuff like bagels and sephora gift cards, maybe even local micro-brews, and a “festive” environment where people will just sign up because “hey, why not.” Then they’ll get their first premium bill; and their first “sorry this isn’t covered;” and “your deductible is $10K”; and your network of doctors does not include 85% of doctors working in your area, etc. etc.

        Ha ha. Navigators.

      2. Lambert Strether Post author

        Today’s Republicans are so stupid — or it’s all even more kayfabe than I think — that they can’t even make the obvious connection that the purpose of the navigators is to funnel tax dollars to politically wired non-profits. It’s just obvious “walking around money.”

        * * *

        There’s also the issue of what happens if a Navigator gives you bad advice on filling out the form — which is done under penalty of perjury, let us remember. Or what happens when a Navigator says one thing, and another source (say, the State) says something different.

  11. Ms G

    ObamaCare (FrankenCare) is like a beautiful field of wild grasses, daisies and buttercups that turns out to have grown on a field of lethal toxic waste secretly dumped years ago by KleptoCorporation. One day people discover that all the streams feeding from that beautiful field and all the kids and adults who played in it on sunny summer days are slowly dying off en masse.

    1. Lambert Strether Post author

      More like a field of weeds that I can forage in if I buy the right field guide and learn which plants are edible and which are poisonous.

      And then, yes, on a toxic waste dump, absolutely.

      1. Ms G

        But there aren’t any edible plants in that field, by definition, because Magic Market (for Insurance Companies), i.e., they win-you lose (it’s structural).

      2. Ms G

        Also … it’s definitely a beautiful field of wildflowers, the “sparkly pony” of Obama’s “health initiative.”

        1. craazyman

          maybe it’s a field of wheat grass.

          has anybody ever tried a shot of wheat grass juice at the health food store? they have signs saying how good for you it is.

          green signs with sunshine that look like wellness itself

          there’s a silver machine like a blender and they put the grass in the machine and the blades juice it into liquid.

          then they hand it to you in a paper cup, like the cups at the dentists when you’re in the chair and you have to clean out your mouth.

          little paper cups.

          when you take your first sip it tastes like lawn mower clippings, and your stomach wrenches. remember cleaning out the wet grass clogged under the mower in the yard? remember the smell? that wet grass smell?

          imagine drinking that smell.

          that’s wheat grass.

          I know why it must be healthy. Because when it gets into your body all the germs and viruses and bacteria that make you sick find it so repulsive they leave. They make you puke so they can ride the puke out of your body and onto the floor or a wall or the carpet or even into the air. they’ll take their chances in the air.

          that’s wheatgrass

  12. Hugh

    The great healthcare debate took place from March 2009 to March 2010. Here are a few quotes from my old Obama Scandals List which I stopped adding to in November 2011 (There were simply too many, too entwined.)

    Obama at a March 26, 2009 townhall,

    And so I don’t think the best way to fix our health care system is to suddenly completely scrap what everybody is accustomed to and the vast majority of people already have. Rather, what I think we should do is to build on the system that we have and fill some of these gaps.

    http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-at-Open-for-Questions-Town-Hall/

    Or on June 24, 2009:

    The problem is, is that we have a employer-based system that has grown up over decades. For us to completely change our system, root and branch, would be hugely disruptive and I think would end up resulting in people having to completely change their doctors, their health care providers, in a way that I’m not prepared to go.

    http://www.whitehouse.gov/the_press_office/Remarks-By-The-President-In-ABC-Prescription-For-America-Town-Hall-On-Health-Care-6-24-09/

    This by the way is completely untrue since the only thing that would change would be the payer, not the providers. And again on August 14, 2009 at a townhall in Belgrade, Montana, Max Baucus’ home state:

    Every one of us, what we’ve said is, let’s find a uniquely American solution because historically here in the United States the majority of people get their health insurance on the job. So let’s build on that system that already exists — because for us to completely change that, it would be too disruptive.

    http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-in-town-hall-on-health-care-Belgrade-Montana/

    What Obama didn’t say was that the government through Medicare, Medicaid, Tricare, and the VA already accounted for one of every two dollars spent on healthcare in America. So far from being something alien to the American “spirit” government as payer in healthcare is a massive presence, already.

    1. banger

      Wonderful exposition of the issue. What is little understood is that the gov’t spends as much now as some countries spend for covering everyone–the figure I read was 9% of GDP.

      The left abandoned the left essentially by supporting Obama. He was never even close to being on the left. He may be a good guy, who knows–I’ve met the very charming people who have killed people–I don’t hold it against them but still…. We have to repeat this–Obama was selected and vetted by corporate oligarchs who run a far tighter ship than anyone realizes because we still, despite obvious evidence, believe that the mainstream media basically gets it right. I will claim here (again) that everything they say is a lie even when it’s true.

    2. humbug

      I’m sorry, but if part of my negotiated salary is a health insurance package, and suddenly there is a different payer of that cost, the only beneficiary is the business.

      1. Yves Smith

        No, when I was in Australia, I had many people ask me about the American insurance, totally perplexed that it could be employer-based for those that did have it. As one cab driver astutely remarked;

        That should be illegal. It gives the employers too much power over the workers. You are close to being a slave, you don’t dare rock the boat out of fear you’ll lose your health benefits

  13. Hugh

    And another snippet:

    On the government side, Obama fixed his sights on Medicare and Medicaid. As he said on June 24, 2009,

    Medicare and Medicaid are the single biggest drivers of the federal deficit and the federal debt — by a huge margin.

    Note no mention of tax cuts for the rich, unnecessary wars, an oversized military, and the massive bailouts for bankers going on at the time.

    http://www.whitehouse.gov/the_press_office/Remarks-By-The-President-In-ABC-Prescription-For-America-Town-Hall-On-Health-Care-6-24-09/

    And in his September 9, 2009 speech to Congress,

    Reducing the waste and inefficiency in Medicare and Medicaid will pay for most of this plan.

    http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-Congress-on-Health-Care/

    1. Ms G

      Holy Toledo. This really is like dumping people by the thousands. Everything except the fake soap bars.

      And noting the entwinement of the forced destruction of American households:

      “Health insurance has been one of the only employee benefits for instructors in an era when state-funded colleges and universities have cut most faculty positions to part-time.”

      First they get rid of tenured faculty but give adjuncts a bone (health insurance); then they eliminate health insurance for the adjuncts. Next coming up must be eliminate half the adjuncts’ meager pay and automatically sign them up for Food Stamps.

      This is another state initiative, by the way, that illustrates how any “customers” of ObamaCare Insurance Products will only come into being through ham-fisted coercion and/or marketing deception. Some product.

  14. dolleymadison

    This. Is. F$cking. Horrible. THey can actually take your estate for the priviledge of being forced to take insurance. What about Social Security Payments? Will those be confiscated as well?

    1. Lambert Strether Post author

      Here’s another one. ObamaCare provides subsidies for tax credits. So, how about student loan defaulters? Does the tax credit for ObamaCare end up with the student loan people?

  15. The Rage

    Yeah, Obamacare is so awful………I used it to knock my premium down 10% for the next year just on the threat.

  16. chicagogal

    1. Obama wanted to prove that he could do what Clinton couldn’t with this monstrosity.

    2. Pelosi famously (infamously?) said before the vote: “We have to pass the bill so that you can find out what is in it, away from the fog of controversy.”
    http://blog.sfgate.com/djsaunders/2012/10/11/nancy-pelosi-says-she-read-obamacare-bill/

    3. As Lambert points out, Medicaid will take your assets when you die to repay what was spent for you, but he didn’t go into the fact that Medicaid is a means-tested program. While someone may be “eligible” for Medicaid is by no means a guarantee that they will “qualify” for it because the official poverty guidelines are so far out of line with reality that millions of people will “earn” too much to get it. There’s also the pesky little problem of the $2,000 asset cap.

    If you are one of the millions forced into the Medicaid program and don’t qualify based on assets or income, they do offer a “spend down” program with your medical expenses in order to receive the benefits. So unless you have enough ongoing medical expenses every month to get below the line, you’ll certainly have months where you have no coverage. How does the law address that problem?

    1. Lambert Strether Post author

      ObamaCare is all about throwing people into buckets for eligibility determination. Inevitably, people land between buckets. Too “rich” for Medicaid, too poor to buy decent insurance is one example of that happening.

      It’s also the insistence on eligibility determination that makes the exchanges such a hairball from a systems architecture and an implementation perspective. Checking with the IRS, DHS, consumer credit agencies, and the various state programs is not a simple thing, either from the front end perspective (designing the user experience) or the back end (data integration). Make health care a right and go single payer and the nightmare disappears, because Medicare’s architecture is simple and clean. Complexity is the enemy of quality, as they say in software engineering.

      Now, to be fair, ObamaCare’s complexity provides plenty of opportunities for Democratic-leaning non-profits to collect walking around money as navigators, and plenty of opportunities for “creative class” web site programmers, public relations specialists, and designers to cash in building the exchanges, so we’re totally in “it’s an ill wind that blows nobody good” territory here. “Jobs for the boys!”

      1. Philly Dix

        You don’t give info tech enough credibility, companies are now working lucratice contracts to get ‘er up and running. Lucrative almost goes hand in hand with doing a half assed job, just look at the massive waste (that is known about at the Pentagone). Or the gravy ladled unto those who worked the great fraudclosure review. That said. the template has been written by legislators, and missing the bucket seems to be a feature not a bug.

        Reminds me of this:
        http://www.huffingtonpost.com/2012/09/07/florida-unemployment-benefits-difficult-rick-scott_n_1866356.html

      2. tongorad

        Obamacare: designed for the rentiers, by the rentiers. Your health is my profit center.

        Also, the complexity serves as a handy fog of war for the propagandists and obamabots.

  17. craazyman

    sounds like dying is less painful than trying to figure this sh*t out.

    I mean really. Who thinks up this stuff? A gang of deranged lawyers and morons. The morons doing the thinking and the lawyers doing the writing. Or is that a redundancy?

    if you’re a normal, sane person the world is getting more and more like Masada. You’re just the Jews in the caves and the Romans are climbing the walls.

    What do you do now?

    Probably what they did.

  18. Vlad

    We who live in Canada, just sadly shake our heads as we watch Americans go through all these painful contortions in order to maintain a “free” market solution to health care. All this just so a handfull of large health insurance corporations can skim billions off of the system. Some day Americans will realize that the only solution is a universal single payer system such as the rest of the world has. Until then, Canadians will watch with bemusment and sadness.

    1. sleepy

      Actually, while the rest of the industrialized world does have universal coverage, much of it is not single-payer. Someone will correct me if I’m worng, but I believe Germany for example offers healthcare through tightly regulated non-profit insurance companies.

      I believe similar plans exist in most EU countries.

      While there are probably others, the only single-payer healthcare systems that I’m aware of are Canada and the UK.

  19. Steven

    I find this discussion deeply depressing.

    It is desperately important that leftward leaning people not fall into the same kind of paranoid politics that is poisoning the right.

    I understand that progressives are disappointed that obama isn’t a more aggressive fighter for progressive ideas, but obama is not some wolf conspiring to betray and devour us. He is a man of conciliatory temperament trying to find some way forward in the corrosive politics of our age.

    Surely there are two key points we need to keep in mind.

    1. There was no possibility, with the present political balance of power, to get single payer medicare for all. I myself prefer this solution, but acting as if this was possible, if only obama had been willing to go to the wall for it, is a delusion of the left and it leads to this conspiratorial thinking. That isn’t going to happen until progressives gain more power and can get more people supporting their agenda into Congress. Blaming obama for this is silly. Yes, obama could have put it on the table and fought for it. On the other hand he may very well be right that if he did so there would have been no health reform at all. Which brings me to the 2nd point.

    2. For all its flaws is there really good reason to believe that nothing at all and a continuation of the dysfunctional system we had would have been better? I don’t believe this. I think the affordable care act will be a step in a better direction. It isn’t going to solve everything.

    On the issue of estate collection under medicaid I think people are making a lot of assumptions. I would be very interested in seeing data about how many medicaid cases have had such collection sought. As I understand it this was put into place as part of the way of dealing with long term elderly care in cases where the elderly die with assets. This is not supposed to be happening is it(i.e. elderly people on medicaid are not supposed to be dying with assets)? Medicaid is supposed to kick in, for long term care, after an elderly person has spent down their assets and is essentially broke and no longer able to care for themselves. For years families would transfer assets to the children before death and then put parents on medicaid for nursing home care. The government started cracking down on this because medicaid was never intended to be a state subsidy for asset preservation/transfer to future generations. The estate recovery was put into place because an elderly person shouldn’t be on medicaid if they have any assets to recover.
    Now it does appear to be true that a provision of the law was written very broadly to allow extending recovery to other cases and we don’t yet know whether the government will ever try to engage in such recovery in relation to medicaid expansion. I would agree that there should be clarification on this point and the law should be tightened up. Still, in the meanwhile, would it really be better to maintain what we have now, where many of these people wait until they get deathly ill and then go to the emergency room because they have no health insurance or care access? If you asked many poor people if they would rather be sick or die, rather than have access to health care, in order to pass more assets onto their children how many would say yes? If people really felt this way then most retirees(who are spending down assets as they age) would commit suicide tomorrow in order to maximize what they can pass on to their children.

    1. Hugh

      As we used to say there are some who are koolaid drinkers and then there are those who mainline it. You seem to be in the latter group. Obama has been President for 4 1/2 years now. There are no progressives in his Administration. At the same time, he has filled major posts with Republicans and neoliberal Clintonista retreads. Obama has never fought for any piece of progressive legislation, unless you want to go all the way back to the fairly ineffectual Lucy Ledbetter Act, and even that was pretty much a gimme.

      I mean we have debunked your pro-Obama arguments years ago. Obama assumed an imperial Presidency with vast and largely unchecked powers. Yet according to you, he can barely tie his shoes because he is just so damn conciliatory, or any of the other buzz words: cautious, bipartisan, into 19 dimensional chess, whatever. So how is it then that Obama has aggressively embraced the national surveillance state, the war on whistleblowers, and the state secrets defense. Why did he sign off on the torture and prosecution of Bradley Manning when at the same time he let all the Wall Street banksters (responsible for the greatest interconnected financial frauds in human history) walk, and not just walk, but bailed them out to the tune of trillions?

      On Iraq, Obama could have pulled the troops out by the end of 2009, less than a year into his Administration, instead he kept them there 3 years and tried to keep them there beyond the expiration of the SOFA except that the Iraqis refused because of the verdict in the Haditha trial. He not only didn’t pull troops out of Afghanistan, he escalated emulating Bush’s Iraq “surge” and there were still more US troops in Afghanistan when he started his second term than when he started his first. He has embraced and expanded the drone wars. He waged a war in Libya, openly flouting the War Powers Act. He has given himself the power to kill Americans like Anwar al Awlaki with zero due process anytime anywhere in the world.

      Most Americans never left the recession which began in December 2007. Yet Obama has written them off just as he understates and has written off the unemployed, just as he boasts about what jobs he has created without ever mentioning that they are crap jobs.

      Healthcare still was notable even for him for being a breathlessly audacious sellout.

      So we have this President who not only has never fought for any progressive cause but has consistently fought against them all, who has governed to the right of Nixon, Reagan, and even Bush and you say, after 4 1/2 years of this, we should cut him more slack. Can you possibly be serious?

    2. Code Name D

      “1. There was no possibility, with the present political balance of power, to get single payer medicare for all. I myself prefer this solution, but acting as if this was possible, if only obama had been willing to go to the wall for it, is a delusion of the left,”

      Self-defeatism is not an effective strategy for change. But it is a very good strategy to prevent or slow change. There were plenty of strategies forwarded for healthcare reform, but all of them require genuine long term efforts, which include dealing with inevitable setbacks. Obama chose the quick-fix route, to pass any thing for the sake of just passing something that he can sign his name too and take his victory lap.

      His victory will cost us as it may be several more decades before we can even raise the issue of our dysfunctional healthcare again, let alone seriously discuses reforms.

      The delusional thinking is assuming that any thing is automatically better than nothing, without seriously considering exactly what it is being passed, and what the alternatives are. A bridge fifty feet long is not automatically better than a bridge forty feet, when trying to cross a sixty foot wide span.

      “2. For all its flaws is there really good reason to believe that nothing at all and a continuation of the dysfunctional system we had would have been better? I don’t believe this. I think the affordable care act will be a step in a better direction. It isn’t going to solve everything. ”

      The AHAA doesn’t solve any thing. Indeed, it only pretends to deal with certain aspects of healthcare insurance, and doesn’t really do any thing to solve the issues found there. It’s a bit like clamming that a new gas card will fix that old clunker rusting away in the back yard. What it does do is further entrench the existing free market approach to insurance, which has already demonstrated its failure.

      Obama’s starting position was largely adopted from the Massachusetts plan AKA RomneyCare. If Obama was just being practical, then why did Obama continue to defend this plan when Republicans turned on it?

    3. lambert strether

      You’re depressed because you ought to be depressed. You’re backing a bad man and a bad policy. Single payer advocates don’t get depressed, in my experience, because they’re fighting for a policy that is just and moral.

    4. LucyLulu

      Medicaid is run by the states so I can’t say for sure if this remains true for all states, however, in many states at least, a person’s home is exempted from being counted among their assets for purposes of Medicaid eligibility. Their car may also be excluded. Once the person dies, any proceeds from the sale of the home and car would be used first to repay Medicaid.

      Many elderly actually do avoid getting medical care and other things they need in order not to spend their children’s inheritance. There were reports of some threatening to commit suicide before the new year when there was talk of reinstating the “death tax” with Clinton level exemptions ($1M I think) when the Bush tax cuts were expiring in 2010, after having no estate tax in 2009.

    5. steven

      I don’t see how one can call it a quick fix. We have been arguing about this for the better part of a century. Single payer for all is further from being a possible reality now than it was 40-50 years ago. If, as you say, it requires long term effort then keep making the effort. You accuse me of defeatism but then claim that the aca removes any hope of additional change. What is this if not defeatism. If we can convince the american people of the soundness of single payer and get them to act on this when voting for Congress, then single payer will be as possible tomorrow as it was 4 or 5 years ago. If we can’t convince them then its all moot.

      I don’t think that anything is better than nothing. There are many things, like the conservative agenda of abolishing medicare, medicaid, social security etc., that are far worse than doing nothing. I have pretty carefully considered what was passed and what the alternatives were. When I consider the alternatives I don’t consider all the dreams of what could be in an ideal world. I consider the alternatives that can actually get done given the present balance of power. As I see it there were only two alternatives that ever had a chance of happening. Something similar to the aca, or nothing. I think it is far too early for all this speculation of how the affordable care act will accomplish nothing. If it significantly reduces the number of uninsured and reduces the pain and fear that the uninsured are forced to live with, reduces the escalation of health care costs and, when all the heat dies down, becomes something that people become reasonably happy with, then it will also reaffirm that government action can be beneficial and that will all be a very major set of benefits. It is easy for comfortable people with health insurance to say that we should continue to maintain people in misery, rather than do something to ameliorate that misery, because to ameliorate it might blunt more radical change but are we concerned more about the politics of it or about human suffering? It is grossly immoral and predatory to maintain suffering for political effect when you have within your power some ability to lessen that suffering.

      I don’t understand the argument that the aca entrenches the free market approach. The free market approach is already well entrenched and becoming more entrenched every day, we presently ration health care by ability to pay, and most people are convinced that the government can do nothing to help. I don’t believe the aca is a great solution but I believe it will help, relative to doing nothing, which was the only viable set of the choices the present climate provided.

      So by all means continue the fight for single payer. I will continue to advocate single payer. But I will do so with the knowledge that, in the mean time, something was done to help us take at least a few steps forward from where we were.

      As for my drinking koolaid. I have never bought anyone’s koolaid. This is why I am not so disillusioned by obama as many have been. I continue to be frustrated by the paranoia of American politics, which is increasingly infecting the left wing as well. This vision that obama isn’t just an imperfect man, of moderate politics, trying to navigate an appalling time and political balance but that he is evil, plotting dark conspiracies, portraying himself as leftward leaning when he is really some sort of arch conservative trying to seduce the public. I wish I could make the left understand that this is self-defeating and only plays into the hands of the right wing fanaticism that is growing in power every day.
      By all means critique obama’s policies and continue to propose better policies but please stop with this nonsense of how obama is no different from the right wing and how its all a dark plot. It isn’t. It is crucial that decent people remain sane in an insane world and not get sucked into this logic.

      1. Code Name D

        Forgive me, but I can not resist dismantling this nonsense.

        Steven said, “Single payer for all is further from being a possible reality now than it was 40-50 years ago. If, as you say, it requires long term effort then keep making the effort. You accuse me of defeatism but then claim that the aca removes any hope of additional change. What is this if not defeatism.”

        Betrayal

        Obama has sabotaged single payer as every opportunity. Is it any wonder we are now further from these goals than before.

        “If we can convince the american people of the soundness of single payer and get them to act on this when voting for Congress, then single payer will be as possible tomorrow as it was 4 or 5 years ago. If we can’t convince them then its all moot.”

        The people area already convinced by a significant margin. During the healthcare debate, independent polls routinely give single payer reforms a majority by two thirds when compared with privatized strategies. http://pnhp.org/blog/2009/12/07/two-thirds-support-2/ And this support came despite constant media bashing of the idea and zero support from the Democrats.

        “I don’t think that anything is better than nothing.”

        You obviously do not think this, or you would not have said the following.
        “When I consider the alternatives I don’t consider all the dreams of what could be in an ideal world. I consider the alternatives that can actually get done given the present balance of power. As I see it there were only two alternatives that ever had a chance of happening. Something similar to the aca, or nothing. I think it is far too early for all this speculation of how the affordable care act will accomplish nothing.”

        “I don’t understand the argument that the aca entrenches the free market approach. The free market approach is already well entrenched and becoming more entrenched every day, we presently ration health care by ability to pay, and most people are convinced that the government can do nothing to help.”

        Obviously, you do understand then, you just refuse to admit it.

        “I don’t believe the aca is a great solution but I believe it will help, relative to doing nothing, which was the only viable set of the choices the present climate provided.”

        This is simply false. There are alternative strategies out there. You are simply trying to argue from ignorance here.

        1. steven

          So you have alternatives, including single payer.

          For any of these alternatives to become reality they have to get passed in Congress. If none of them get passed then you end up with what we had before the aca. That is you end up with no change. What alternatives had a path through Congress?

          It would be accurate to say that obama did not fight for single payer. But saying that obama sabatoged single payer suggests that you believe there were the votes in Congress to get single payer passed, but that obama undermined this.

          Do you think that single payer had the votes in Congress to get passed? Do you think, if obama had fought for single payer, that the outcome would have been that enough people in Congress would have been persuaded to change their vote to get single payer passed?
          If the answer is no, that single payer didn’t have the votes and wouldn’t have the votes, then it is pretty unfair to blame barak obama for this or to say that he sabatoged single payer. Why not just state more accurately that he was not willing to fight for something that he knew wasn’t going to get passed anyway?

          1. Code Name D

            Again with the self defeatist attitude. “There is no chance for real reform – so let’s pass fake reform instead because that we can do.”

            You are pretending that reform is a one-shot deal. Even Obama himself said that AHA was only the preverbal “first step.” But he was clearly lying when he said that as at the time he had no follow up legislation in development, or even talking about additional reforms to come. And sense AHA has been passed into law – the topic can’t even be broached in the Whitehouse, unless it’s Republican talk of repeal.

            Just because something is hard, or even seemingly impossible, doesn’t mean it is not worth doing. And failing doesn’t mean quitting either, unless you support Obama apparently.

            It’s obvious that there weren’t the votes to pass single payer through congress. But single payer remains popular with the public. So you put it on the floor and make them vote it down, make them vote no on a popular reform bill. Not only would some of them not be re-elected, but their opponents would specifically run on a platform of supporting the reform bill.

            When the bill comes to the floor again, their will be more support. You keep doing this, running out the opponents, and electing new supporters that eventually the bill will pass.

            This is how we got anti-tobacco legislation. This is how states are recognizing gay rights; this is how SS got passed. This is how Republicans do business. So we know this works.

            Instead, by keeping it off the table, Obama gives political cover to the anti-reformers. They get to pretend that they support healthcare reform, when they don’t. Just as you pretend Obama’s bill actually offers beneficial change.

    6. washunate

      Steven, I’m confused, are you talking about the guy who went on national TV and said abortion isn’t a healthcare issue? The guy who said all options were on the table except the options that would actually solve the problems? The guy who routinely mocks drug reformers? The guy covering up financial fraud and war crimes?

      Are we talking about the same guy here?

      1. steven

        Yes we are talking about the same man. I don’t believe that the reason these things are happening is because the present president has a secret malignant agenda.

        Is there any reason, given what we know about human nature, to believe that a human man, however good his intentions, is going to become president, enter a government bureaucracy of tens of thousands of people that has a long history of crimes and protection of predation, theft, and violence and is going to be able to transform that system by force of his own will? The president himself has said a number of times that he has to be pressured and forced into doing the right thing. The pressures that he is surrounded with the vast majority of the time are trying to drive him to do the wrong thing. The inertia of the age and the dominance of conservative ideology is trying to drive him.

        For me the key question is this. Does the fact that obama, has continued appalling governmental policies, mean that there is no difference between him and people like dick cheney? Are his intentions as malignant as the intentions of the right wing fringe? Is it irrelevant whether a democrat is in power in washington or a republican is in power?
        If the answer to these things is yes then by all means tear him down at every opportunity.

        But if the answer is that there is a difference, even though we a frustrated by barak obama not reversing a lot of these miserable trends, then we need to consider the consequences of our developing a conspiracy and betrayal message about this president. Many on the left seem to believe that if we do this we are increasing the chances of ending up with a more progressive president in future, but I think the more likely outcome is that we will end up with a republican president and, given the direction the republican party is trending, an ever more right wing president.

        I want to be clear that I am not advocating that no one should ever criticize the president. I criticize policies frequently. But this message of betrayal and that he is wolf in sheeps clothing conspiring against us is inaccurate and corrosive and it isn’t going to increase the likelihood of a more progressive political power in America.

        1. washunate

          Ah, but I’m not frustrated with Barack Obama. I accept what he stands for, and I disagree.

          You seem to be the one frustrated, because you think spying on American citizens somehow happens despite the President’s best intentions.

  20. hondje

    Coming late to the party, but tax credits do no good for the millions of poor people who have defaulted student loans.

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