ObamaCare’s Relentless Creation of Second-Class Citizens (2)

By lambert strether of Corrente.

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

When talking about ObamaCare, single payer advocates sometimes hear “But the ACA helped me,” or “the ACA helped my sister,” and so on. Of course, a program as large as ObamaCare is bound to help somebody; it’s just that single payer advocates want everybody to be helped in the same way that you or your sister were. And that’s the problem with ObamaCare: It doesn’t treat health care as a basic human right that should be guaranteed for all. Instead, ObamaCare uses a complex and intricate Rube Goldberg-esque system of eligibility rules to throw people into various buckets by past (and projected) income, age, existing insurance coverage, jurisdiction, family structure, and market segment. In a system so complex, people will inevitably be thrown into the wrong buckets, or land between buckets, because their personal circumstances don’t mesh well with the Rube Goldberg device.* Some citizens get lucky, and go to Happyville; others, unlucky, end up in Pain City. The lucky are first-class citizens; and the unlucky, second class. In an earlier post, I gave three examples of the whimsical and arbitrary distinctions that ObamaCare makes between citizens who should be treated equally; in this post, I’d like to give three more.

First, if you’re in the Beltway political class, you could a lucky winner, and a first-class citizen. If you’re in any other class, you’re a second-class citizen, by definition. This story has been simmering for a long time. Politico:

Dozens of lawmakers and aides are so afraid that their health insurance premiums will skyrocket next year thanks to Obamacare that they are thinking about retiring early or just quitting.

The fear: Government-subsidized premiums will disappear at the end of the year under a provision in the health care law that nudges aides and lawmakers onto the government health care exchanges, which could make their benefits exorbitantly expensive.**

Democratic and Republican leaders are taking the issue seriously, but first they need more specifics from the Office of Personnel Management on how the new rule should take effect — a decision that Capitol Hill sources expect by fall, at the latest. The administration has clammed up in advance of a ruling, sources on both sides of the aisle said.

Rep. John Larson, a Connecticut Democrat in leadership when the law passed, said he thinks the problem will be resolved.

“If not, I think we should begin an immediate amicus brief to say, ‘Listen this is simply not fair to these employees,’” Larson told POLITICO. “They are federal employees.”

Yeah, and we’re consumers citizens. Where’s our amicus brief? I don’t have much sympathy for the lawmakers (supposing the country to retain the rule of law), almost half of whom are millionaires, and most of whom view “public service” as an ill-paid internship on the road to the real money. I have more sympathy for the staffers, some of whom are known to dine at Taco Bell. That said, this “problem,” when push comes to shove, will be “resolved” in exactly the same way that the problem of  flight delays from laying off controllers during the ongoing sequester was resolved: Congress immediately put those controllers back to work, because they wanted to get back to the district as fast as they could. Nothing else changed. So, on ObamaCare, the solons and the staffers will make sure they get taken care of, and put the rest of us on the bus to Pain City.

Second, if you’re covered you’re a first class citizen. But if you’re not, you’re a second-class citizen. After all, ObamaCare says that health insurance is desireable, even ethical (even to the extent of using the Orwellian label “shared responsibility payments” for the mandate’s fines and penalties***). But not even the most dedicated apologists claim that ObamaCare will be anywhere near universal; only 7 million will be signed up in the first year (double that for expectations management, and it’s still pathetically low). When ObamaCare is fully implemented, it will have expanded coverage to 30 million, leaving 26 million uncovered. As one rising Democratic politician said in 2007:

In the 2008 campaign, affordable, universal health care for every single American must not be a question of whether, it must be a question of how. We have the ideas, we have the resources, and we must find the will to pass a plan by the end of the next president’s first term.

[W]e can’t afford another disappointing charade in 2008. It’s not only tiresome, it’s wrong. … Wrong when 46 million Americans have no health care at all. In a country that spends more on health care than any other nation on Earth, it’s just wrong.

So if it’s “just wrong” when 45 million aren’t covered, why isn’t it “just wrong” when 26 million aren’t covered? And what do you call those 26 million but second class citizens?

Third, if you’re targeted by Enroll America, ObamaCare’s marketing operation,**** you’re a first-class citizen. If you’re not, you’re second class. Reuters describes how ObamaCare is about to be marketed:

The effort will focus on selling the merits of the Patient Protection and Affordable Care Act to 2.7 million Americans with little or no health coverage, who are 18-to-35 years old, mostly male, and largely nonwhite, including many who are black or Hispanic, officials involved in the planning told Reuters.

The idea is to get them enrolled in private health plans through online marketplaces that will offer coverage in all 50 states at prices defrayed by federal subsidies, which many should qualify for because of their lower incomes and lack of adequate insurance.

Participation of young consumers is central to the success of the new state healthcare exchanges, and Obama’s reform law, because the young tend to have little need for medical services and are cheaper to insure. That will compensate**** for older, sicker people who are expected to sign up in droves because the law bans discriminatory pricing and treatment for those with preexisting conditions.

Current and former administration officials said the outreach will employ the same methods used in Obama’s reelection campaign, which relied heavily on social media, grass-roots organizing and demographics to reach young people, minorities and women. Members of the young target audience tend to be concentrated in major metropolitan areas, and about a third are believed to live in just three states: California, Texas and Florida.

The objective is to “surround” low-income young adults with messaging about the healthcare benefits by tapping channels more apt to reach them: cable television, radio, churches, Facebook, Twitter, YouTube, online chat rooms and youth-oriented magazines. The White House and HHS are also in discussions with celebrities, sports leagues and franchises that may be willing to help promote coverage.

Well, who are these “older, sicker people who are expected to sign up in droves”? As it turns out, HHS’s Center for Medicare and Medicaid Services commissioned a study that breaks them down into marketing segments, and we have the slides. There are six segments in all, three of which are not worth marketing to (including the “vulnerable & disengaged), leaving the remaining three: “Sick, active, & worried,” “Healthy & Young,” and “Passive & Unengaged.” 


As we have seen, Enroll America is going to target the middle column for a trip to Happyville: The “Healthy & Young.” Presumably, the “droves” will come from the left-hand column, the “Sick, Active, and Worried,” exactly because they’re “active” and “worried,” and not from the right-hand column, since that segment is “passive” and “unengaged.” Will Enroll America’s marketing be able — or even seek — to transform them to active and engaged health insurance consumers? If so, they’re not planning for it. Here are the barriers and motivations for all three segments to seek coverage:


First, Enroll America’s marketing will be addressed to low-income young adults, and the “Passive & Unengaged” non-droves are less likely to be young. Second, as the slide above shows, they are not responsive to mass media, knocking these channels Reuters mentions — “cable television,” “radio,” “youth-oriented magazines,” “celebrities,” “sports leagues,” and “franchises” — out of the picture. Finally, let’s look at Internet usage:


As we see, the “Passive & Unengaged” are much less likely to use the Internet, which knocks out the “Facebook,” “Twitter,” “YouTube,” and “online chat room” channels. That leaves — at least as this story describes Enroll America’s marketing strategy — the “churches” as the sole remaining channel to reach the “Passive & Unengaged.” I don’t see how that can possibly be enough.

According to the study, the “Passive & Unengaged” are about 20% of the uninsured population. If there are 56 million uninsured, that would mean that Enroll America is, in essence, sending some large fraction of 11,200,000 citizens to Pain City, rather than making an attempt to engage them. Does that make them second class citizens? I think it does.*****

Lebensunwertes Leben, donchya know…

NOTE * ObamaCare apologists, at this point, play the incrementalist card, and say that we are only at the beginning of a long process, and that many improvements and reforms have yet to be made. They ignore the fact that we have proven systems of universal coverage. We have at least one in the great Republic to the North, and only one eligibility rule change is needed to implement that system here: Lower the age of eligibility for Medicare to 0. ObamaCare apologists, who consistently refused and still refuse to put single payer “on the table” are in essence performing a medical experiment on the American people while refusing them informed consent. Ask your doctor how they feel about the ethics of that.

NOTE ** ObamaCare apologists, at this point, play the “no rate shock in California” card. This from Trudy Rubin of CJR deconstructs the public relations.

NOTE *** With a single payer system, “shared responsibility” would not involve handling a chunk of rent to the health insurance companies, since the tax system would handle this duty of citizenship.

NOTE **** Of course, with single payer Medicare for All, there would be no need for the government to act like a private entity and adopt the actuarial business model, as Obama, the Democrats, and Enroll America have; providing for “the general welfare” would come first.

NOTE ***** One might give consideration to the idea that Enroll America — which is full of political operatives — is not like a political campaign, but is a political campaign; the opening shots of Campaigns 2014 and 2016. Of course, it could be a coincidence that voters in CA, FL, and TX are being targeted, and those voters in Obama’s youthful, black, and Hispanic demographic. After all, an alternative approach would have been to target those who actually need care. Given how adept the tech dude[tte]s of Team Obama are at slicing and dicing data, one must believe that approach was considered, and rejected. 

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Chromex

    The only thing I have to add is that the arbitrary categories identified above are insurance business model categories which is why they make no sense from the standpoint of providing health care ( as opposed to crappy insurance no one can use) to those who have not had health care. I care not that 90% of people are “covered” if they are covered by a plan in which they pay 40% of all their health care expenses AND premiums. Try adding up the cost of bypass surgery and premiums and see if you consider yourself “covered” after that. The premiums touted by the advocates for this awful plan you ALSO have to pay= on pain of fines and penalties-even though you get little for them. This isn’t just a bad plan. It is also fascist debt slavery ( Roberts is incorrect- you can’t do anything you want with the taxing power, this is well known to any attorney who remembers law school and his decision is as wrong as Dred Scott) where everyone is in thrall to the almighty insurers. The only upside is that this plan is so bad there may be enough public outrage to change it as its “features” are implemented. AS for the legislative staffers- I care about them only to the same extent that I care about myself. No one should have to be subject to this “law”.

  2. diptherio

    The Administration’s line on Obamacare is absurdist in the extreme. These three paragraphs alone should have any thinking person scratching his/her head:

    The effort will focus on selling the merits of the Patient Protection and Affordable Care Act to 2.7 million Americans with little or no health coverage, who are 18-to-35 years old, mostly male, and largely nonwhite, including many who are black or Hispanic, officials involved in the planning told Reuters.

    The idea is to get them enrolled in private health plans through online marketplaces that will offer coverage in all 50 states at prices defrayed by federal subsidies, which many should qualify for because of their lower incomes and lack of adequate insurance.

    Participation of young consumers is central to the success of the new state healthcare exchanges, and Obama’s reform law, because the young tend to have little need for medical services and are cheaper to insure. That will compensate for older, sicker people who are expected to sign up in droves because the law bans discriminatory pricing and treatment for those with preexisting conditions.

    So, we are expecting low-income (relatively) young people to compensate, i.e. help pay for, older poor people, by requiring the (poor) young to purchase a product they are unlikely to use any time soon. That is sheer genius and utterly humane…NOT!

    And I find it interesting that these young poor people, like myself, who are expected to compensate for the high cost of others’ insurance, will themselves be getting subsidies to help pay for their own insurance. When those who you are expecting to pay more than their share, themselves need assistance, it would appear that something has gone horribly wrong with your program design. Or you’re trying to obscure the fact that Obamacare is just a cover for transferring large amount of government dollars to the health insurance industry (aka Satan’s handmaidens).

    And, of course, let us not forget that lack of health care is the problem we confront, not lack of health insurance. Health insurance, we should all know by now, in no way assures access to health care or freedom from the specter of medical-bankruptcy.

    1. washunate

      Yeah, the idiocy is truly amazing. Not just that leaders can propose this with no shame, but also that so many educated liberals who should know better go along for the ride.

      1. tongorad

        It should be crystal clear by now that “educated liberals” only care about one thing: themselves.

        If ACA was Republican legislation (OH SNAP, IT IS!), they’d be all hot and bothered about it. But since ACA belongs to their precious liberal hero, well, you know the tune.
        Same-same for drone warfare, civil liberties and everything else.

    2. Jim Haygood

      When those who you are expecting to pay more than their share, themselves need assistance, it would appear that something has gone horribly wrong with your program design.’

      From a citizen’s or taxpayer’s perspective, most definitely. But from the standpoint of the industry insiders who actually wrote PPACA, it’s a magnificent engine of rent extraction.

      Sticking to the lowly citizen perspective, though, the elephant in the room is the widely touted claim that the CBO scored Obamacare as reducing the deficit. As Obamacare’s deep-rooted structural deficiencies become apparent, this claim appears ever more absurd.

      Last year, a study by Medicare trustee Chuck Blahous projected that the law actually will increase ten-year deficits by between $346 and $527 billion.


      This conclusion is completely in line with diptherio’s observation that subsidizing the young, who are supposed to subsidize the old, means that somebody’s gotta pay.

      ‘Don’t tax you, don’t tax me; tax that guy behind the tree.’ — Sen. Russell Long

      1. Cynthia

        As some of you probably already know, one of the main reasons to expand Medicaid is to eliminate the disproportionate-share hospital (DSH) fund (aka charity care) that so-called “safety net” hospitals receive to care for uninsured patients. Once the Medicaid expansion program is fully up and running, the charity care program will be completely phased out, at least’s that the goal of ObamaCare — which one of the few positive things about ObamaCare, IMO.

        But what some of you might not know is that these hospitals use these funds not only on the uninsured who are poor, but also on the uninsured patients who are well off in turns of either income or assets. You would think that you would have to be poor, or at least somewhere near the poverty line, to qualify for charity care, but apparently that’s not the case! I have plenty of anecdotal evidence of well-off patients having no trouble at all qualifying for charity care. Hospitals would rather have these uninsured patients sign up for charity care because it’s a lot easier for them to collect money from the government than it is to collect money from a patient, sick or otherwise. Think about it: why go through the expense of hiring a collection agency to get money out of wealthy uninsured patients when it’s effortless and virtually cost-free to get the money from Uncle Sam?

        People with plenty of income and/or assets having their hospital bills paid for by the taxpayer should be wrong, if not fraudulent, but evidently it’s not. Not at all, in fact. Hopefully ObamaCare will put an end to this seemingly fraudulent form of welfare for the well-off, but I’m not holding my breath.

        1. Code Name D

          It’s only wrong from the money POV. So I agree with your conclusion. Why should I lose my house to bankruptcy to pay for that millionaire’s wife getting a breast augmentation?

          But from a social standpoint, I see no problem helping the wealthy from a communal standpoint. In fact, it is ethical to do so. If you see a man injured on the street, clearly you would help the poor man, but would you walk past the wealthy man; telling him to have his Jeave’s help him instead? Of course not, you would help him too and get him the care he needs.

          This is why single payer is so important to me. Obama-care poisons the system and turns the debate away from actual healthcare, to just how we friggen pay for it.

        2. Shirley

          “I have plenty of anecdotal evidence of well-off patients having no trouble at all qualifying for charity care.”

          OK…what about non-anecdotal evidence? And can you please define “well-off?”

          1. Stan Musical

            Cynthia’s vague anecdote doesn’t even rise to the level of Reagan’s “cadillac welfare queens.” Provide links or data or remain as utterly unconvincing as a paid troll.

      2. Nathanael

        Maybe it appears to be a magnificent engine of rent extraction, but it’s foundering on a problem:

        you can’t get blood from a stone.

        All the money being earned by more and more of the population is going straight into the pockets of:
        (1) bankers charging fees
        (2) phone, internet, utilities necessary for work
        (3) shelter (actual home rent)
        (4) food
        (5) student loans (bankers again)
        (6) clothing
        (7) taxes
        in roughly that order.

        Since real incomes have actually been going down for 99% of the population, the companies higher on the rent-extraction list win. There’s jack left for healthcare.

        The problem arises from pursuing the same rent-extracting model for *too long*. Getting *too greedy*.

    3. Banger

      If the ACA was rational and it isn’t then having healthy people help cover expenses for the sicker people would be ok. But because the system is now deeply corrupt and will be, in somewhat different wasy, deeply corrupt it will be very expensive–maybe not as expensive but I doubt it will go down to anything remotely like the OECD average so what is the extra money for that we will continue to spend? Look at the entire industry and you see systemic fraud and criminality in intention and practice and it is so because that’s how the politicians have structured. Few know, for example, that the U.S.G. nearly as much now as the Brits or the Canadians spend on their universal care systems as a percentage of GDP (the gov’t spends 9% of GDP on HC).

    4. Eric377

      The product under discussion is insurance. An insurance product is used from the instance it becomes effective as insurance. Now that insurance might not be a great product, but don’t confuse not making claims with not using the insurance.

  3. washunate

    The NSA is unhappy with your series. Still getting loading problems – on a Sunday morning!

    1. washunate

      P.S., to the universe reading/moderating this – this appears to have been a pretty temporary thing. I haven’t had any problems tonight.

  4. washunate

    “The objective is to “surround” low-income young adults with messaging about the healthcare benefits by tapping channels more apt to reach them: cable television, radio, churches,…”

    This has to be a parody. No way can someone actually engaged in marketing list cable, radio, and church as the first three places to target young people.

    No. Way.

    1. Veri

      The objective is to further impoverish people while using ACA as propaganda. If ACA does not live up to cost cutting, expect Republicans to run the government, fully, in 2016.

      1. washunate

        That’s an interesting comment, because at some level, it assumes PPACA matters.

        I’m perhaps more seditious in this respect – I think it’s irrelevant (probably the biggest insult to the BFD crowd). Outside of a few niche cases, the law simply won’t change much for the vast majority of people. Healthcare was expensive last year, and it will be expensive next year.

        I would actually be quite happy if there was large scale Democratic dissatisfaction with the outcome, because that means we’ve finally reached a turning point from the politics of personality to that of principles and policy.

        1. Nathanael

          The tax on people who don’t get insurance is going to really tick some people off.

  5. sufferinsuccotash, stupor mundi

    Dozens of lawmakers and aides are so afraid that their health insurance premiums will skyrocket next year thanks to Obamacare that they are thinking about retiring early or just quitting.

    You say this as if it were a bad thing.

  6. Ep3

    “the “churches” as the sole remaining channel to reach the “Passive & Unengaged.””

    Interesting that you say the churches because the churches all vote republican.

    1. Yves Smith

      Hah, the other routes would be radio or TV, but they are too cheap to do that (or worse, can’t BEAR to do a broad radio/TV buy that would include….gasp…..programming that targets conservative suburban/exurban/rural Republicans).

      Plus 62% is a pretty high percentage, but the program is so complex that even a very clear explanation is still VERY confusing (notice how NC readers had to debate what the penalties are, and that’s a comparatively simple program feature). Can they be bothered to provide help lines? And even if they do, the IRS has a big error rates on its hot lines, so that’s not a perfect solution.

  7. Jim Haygood

    Like a pit bull masticating a mailman’s ankle, Lambert has sunk his teeth into Obuggercare and just won’t let go. Bravo!

    Costly government outreach programs like Empower America are ineffective because of the mentality of compulsion that underlies them. Since they can’t make you buy, businesses hawk products with keywords like ‘easy,’ ‘convenient,’ ‘fast,’ ‘cheap,’ ‘efficient,’ and ‘time saving.’ Obamacare is none of those things, because it is based on compulsion: sign up, or we’ll sic the IRS on your slacker ass.

    So the shakedown approach is used, leaning on Big Business to help fund absurdly expensive ‘outreach’ aimed at browbeating young adults to jump through paperwork hoops (under penalty of perjury, as Lambert has pointed out) and sign up for coverage that is patently overpriced for their age cohort.

    Probably the soundest reason for working to derail Obamacare is that entrenching a health care system that consumes a larger share of GDP than in any other OECD nation condemns the U.S. to a bleak future of low job and wage growth, thanks to structural uncompetitiveness.

    There are at least 33 better ways to run a health care system: pick any OECD member other than the United States. In-kind health services, such as walk-in neighborhood clinics, are highly cost effective everywhere they are used.

    Helping to discredit Obamacare is one of the most patriotic things one can do. Ridiculing Empower America’s bumbling efforts to sucker and mulct the near-poor is a fine way to start.

      1. Jim Haygood

        No mailmen were harmed in the creation of this post.

        Charles Bukowski had PPACA nailed in the opening line of Post Office:

        “It began as a mistake …”

    1. Banger

      One of the terrible things that the left did was to categorically reject all Republican critiques of ACA. Yes, they are often wallowing in resentment and hatred of the poor but there was more to the critiques than just that. But no, the Democratic Party and phony leftists insisted this was the path towards sanity–well it’s a little insane now but we can fix it. Sh!t no–I f!cking know Washington and how stuff works there and that is most particularly how you do not reform a system by making in more complex and more game-able. Armies of lawyers who wrote the damn thing are combing for little pieces of the legislation they can drive their fraudulent assess through–that’s always the pattern in modern legislation–the more complex, the more opportunities for corruption.

  8. HS

    Partisan politics has become a fool’s errand and the ACA is no different. The insurance companies wrote it, and then purchased it’s enactment. Anyone who believes that the ACA was enacted for anything other than the benefit of the insurance industry is in for a rude surprise.

  9. Medically Bankrupt Deadbeat

    Lets use accurate terminology here: The American Health Care System is no such thing. It is actually a Medical Extortion System. Its primary function is to extract wealth from people who are in no position to resist– not unlike the rape of women in a village after their husbands and sons have all been executed.

    There are hundreds of examples.

    $5 Kleenex tissues, $10 band aids, $10,000 MRI’s-

    Hospitals billing 10x times as much for the same operation in the same city.

    Hospitals billing 10x as much to uninsured patients as for patients with health insurance.

    Prescription medicines priced 3 to 30 times as much as the same medicine in other countries.

    So called single payer insurance (Medicare) where the co-pay for people who have bought prescription medicine coverage is still more expensive than ordering the same medicines direct from India where 80% of all US label prescription medicines are manufactured anyway.

    The majority of all bankruptcies caused by medical extortion, and within that group most were “insured”.

    Revolution Now!

    1. Dave

      Medical extortion is an excellent term. This is one rant on this blog that has 100% validity. Most of the other complaints involve activity that is mostly voluntary and or of far less consequence.

      One has little choice in this country when it comes to medical care. As of this date, there are no available less expensive “big box” medical options. Since the government and the medical industry have acted together to elevate prices there is basically no consumer choice in this matter. We can be quite sure that Federal and many other government employees will not have to “eat cake” though, as opposed to those in private employment.

      As most of my Canadian contacts stated, “There are no medical bankruptcies in Canada”.

      1. hunkerdown

        “Big box” = HMO, no? Then “Offshoring” = medical tourism. In case of any non-emergency surgery, I’m led to understand having it done in Thailand or India or other well-developed Asian country is worth considering.

    2. Chris E.

      I think this is by far the most important point in all this. There are pro-Obama lobbyists who claim that Obamacare will stop or prevent medical bankruptcies. Nothing could be further from the truth.

      As you correctly state, most medical bankruptcies occur to those who are insured (read: underinsured). And so what Obamacare does is slightly fix the uninsured portion (while falling short of universal coverage) and creates an even bigger underinsurance problem.

      I think this is the 2nd part to the series on the Market state (if I’m correct, Lambert) ? And so I think the important part of this discussion on the ACA in that context is that the market state has exercised amazing power through Obamacare. In essential, objective terms, it is using a client state (nation-state, in this case, the US) and its legal system to mandate consumption of their insurance products, or face penalty! It’s an unbelievable win for those with an interest in the growth and empowerment of the market state, at the peril of the masses of the so-called sovereign state.

      So as a case study I think Obamacare is a perfect demonstration of the lies told about the intentions of legislation, the enormous ideological power of the market state, and an example of the mechanisms by which this power is exercised over client nation states to extract rents.

      1. Lambert Strether Post author

        1. IIRC, RomneyCare reduced the percentage of bankruptcy claims from 57% to 52%. So, this claim by ObamaCare apologists is false.

        2. One critique from the right was that ObamaCare forced people to enter a marketplace. That is what one would expect the market state to do! One critique from the left (by which I don’t mean the Democrats) is that the product (health insurance) is defective. That is what one would expect from a corrupt market state. (Foreshadowing: Is that a tautology?)

        Thanks for remembering the series. Those things are tough to write and I’ve been consumed with the NSA thing and RL matters. So you encourage me.

  10. Eureka Springs

    12.00 dollars an hour for what’s being called “guides” in Arkansas. I call them con men, which infuriates D fenders. They will be deployed in planned parenthood and just about every other clinic or hospital.

    Unapologetically nailing O not care as a caste system and constantly reminding people of our costs compared to the rest of the world and how we get there – expanded tri care or medicare (two alternatives!) gets two familiar old results… name calling and a couple of versions of enemy of better. They would much rather flog (try to make it personal) an argument for universal care at much better costs than anything else. Oh, and those damn republicans!

    What a fool I was for three decades, expecting a party of neoliberals and humanitarian bombers to have any decency whatsoever.

    Never again… not even for dogcatcher.

    1. Banger

      Yep, I’ve certainly learned my lesson–let the weak-kneed vote Democratic–I’m done for now unless the DP changes radically.

      1. Nathanael

        Just make sure you get out and vote for a third party or a write-in instead.

        Remember, when people don’t vote, the Powers That Be know that they’re winning, because people are acquiescing to the removal of democracy.

        1. hunkerdown

          When a government purports to draw its legitimacy from the just consent of the governed, withdrawing one’s turnout is a vote of no confidence. 50% TPTB can pass off as apathy, but a turnout closer to 10% would raise some real credibility issues and uncomfortable questions among the international community.

  11. petridish

    OK, so let me get this straight re: these largely non-white, healthy 18-34 year olds.

    First they’re going to stop and frisk them, then they’re going to swab their DNA for a database, then they’re going to sell them a medical insurance policy to help pay for “healthcare” for the REALLY sick people, then they’re going to turn them over to the for-profit prison system which will rent them out as labor to corporations for 56 cents an hour.

    Whew! Maybe you really CAN make a silk purse from a sow’s ear!

    1. JCC

      And don’t forget they’re also underwater on their student loans, too.

      I wonder where the money is going to come from? The few Middle Class Taxpayers left, I suppose.

    2. washunate

      Awesome description. It’s amazing how close the corporate welfare crowd has come to openly re-embracing slave labor.

      I think that’s why the full employment MMTers push back so hard about this, because the underlying authoritarian impulses look pretty indefensible when discussed so plainly.

      1. Lambert Strether Post author

        “A job for anyone who wants one” is authoritarian why?

        Personally, I’m moving toward GNP Sharing. When a relatively minor tweak like a Jobs Guarantee doesn’t even merit a response from the powers that be, it’s time to up the ante. Plenty of sharing going on for the upper crust, what?

        1. washunate

          I see your point, but I fundamentally reject the premise that ‘a job for everyone’ is what the posts are actually about. Perhaps this rejection is not getting through in the weeds of monetary policy technical details? So I’ll elaborate a bit here on an empirical point and a philosophical point.

          This notion that we’re not spending enough money is trickle down economics wrapped in obscurity through complexity and verbosity. With a dash of ‘don’t worry your pretty little head’ and ‘you clearly don’t understand’ when critiques are offered. These posts are about increasing deficit spending while completely ignoring the plain empirical truth that that’s what we’re currently doing – deficit spending on transfer payments to the wealthy, war criminals, healthcare cartel, and financial criminals.

          This spending isn’t providing net job creation; it is entrenching the extreme concentration of wealth and power destroying our country. As the saying goes, the first rule of hole digging is to stop.

          Old rich white people literally lie to Congress, while low-income young people get sent to prison. How much more bluntly does this need to be put? The USFG is the prime driver of oppression in our current system. Ignoring this central aspect of the federal budget of the past decade (plus) can only be due to reckless negligence – or purposeful embrace of the authoritarian worldview under girding the particular uses of the spending (drug war, TSA, GWOT, IP, tax cuts for the wealthy, financial bailouts, million dollar hospital execs, etc.).

          In addition to that empirical point, the philosophy that ‘work is good’ is inherently oppressive. People don’t need work, they need income (a standard of living, not a thing to do). Confusing the two leads down the path to very centralized, bureaucratic, paternalistic systems that maximize effort rather than output. The whole point of paid work is that people wouldn’t do it otherwise – it is definitionally a Bad Thing, not a good thing, something we want to minimize, not maximize.

          The fewer labor hours it takes to grow our food and educate our children and provide transportation and medical care and so forth, the better! The ideal is to work 1 hour per week, not 100 hours per week. The point isn’t ‘a job’; the point is the quality of the job in producing an output that enhances our quality of life, our standard of living, our wealth.

        2. washunate

          P.S. If you’re into the Job Guarantee specifically (employer of last resort), I would be quite curious to hear your reasons for supporting it some time (and what, exactly, it is you advocate).

          The primary challenge I see is that the devil is in the details. Do you do productive projects or provide free labor to political cronies (sorry, I mean local projects supported by mayors through community groups)? Do you pay minimum wage or living wage? Do you offer medical, dental, life, disability, vacation, sick, holiday, jury duty, bereavement, retirement, etc.? Can a worker be fired? What sort of training and oversight is involved? Is the program run locally or federally? What administrative structure is in place for strategic thought and leadership on everything from staffing practices to technology to anti-discrimination and whistleblower policies? Is it really a guarantee, or are exceptions going to be carved out over time for ex-offenders, substance abusers, mentally ill, terrorist sympathizers, teabaggers, pot smokers, gays, racists…

          JG would be the most massive state program ever in the history of our nation, employing more people than the height of CCC, WPA, and WWII yet without any unifying goal or purpose of what all these people are trying to accomplish. It is fundamentally a political proposal, not an economic one – it is the notion that what is wrong with the American Republic is our Constitutional structure of regulated capitalism, of the blend of public and private. It is the argument that we should abandon the roots of limited government in favor of 21st century socialism. The Bill of Rights should yield to the economic expediency of central planning.

          That’s neither illegitimate nor necessarily wrong. It’s just very different, and backers should acknowledge that major difference rather than trying to hide it in monetary technicalities. The uncertainty of what would happen is itself a major risk factor; we simply have no clue how such a massive shift in government philosophy would impact the behavior of citizens – particularly since the underlying philosophy of group, of collective, of state authority has no current foundation in the American social contract.

          Social insurance is popular and widely accepted, but things like the financial bailouts and domestic spying and drug war and TSA are MUCH more controversial.

          1. washunate

            Or to add a little empirical context, there are about 72 million workers who make less than $25K a year for whatever reason. Many of those reasons, of course, are voluntary.


            So if, say, 2/3 of those workers are involuntarily in that group, that’s about 48 million people. Walmart, for comparison, employs about 2 million people.

            That’s the scale of a JG built around a living wage – running something like 20-25 Walmarts.

            And of course, if a JG is built around a minimum wage, well, what’s the point? $7-8 an hour with no benefits is going to give people enough income to stabilize communities? Ha! That thought can only come from a comfortable liberal academic completely sheltered from the incomes and expenses of people in the real economy.

  12. Ms G

    Super rundown. Now that we have a good idea of how *few* Americans ObamaCare plans to send to HappyVille, I hope that you will write about how HappyVille turns out to be a shanty HooverVille and that the First Class Citizenship only lasts up to coerced enrollment, whereupon you turn into an ACA-entrapped Second Class Citizen.

    Note. It does not seem accidental that the Enroll America Campaign machine is focusing only on forcing people *into* the ACA system. No meaningful focus on how once you’re in HappyVille your HappyVille Card will be pretty much useless as far as buying you any Happy (e.g., 40% “Cost sharing”, $2-3000 deductibles, whatever is “not covered,” etc.).

    “The Affordable Care Act is neither Affordable nor about Care. Discuss amongst yourselves!” (Linda Richmond, paraphrase from “Civil War” episode.)

    1. Jim Haygood

      If only seven million are signed up in the first year as projected, adverse selection should result in STUNNING price hikes in the second year (2015).

      Are we having fun yet?

      1. Ms G

        Yes, Jim. HHS will have to enact a regulation that allows citizen-customers of ACA to buy derivative swaps to hedge against premium increases (not to mention increases in all the other facets of those HappyVille policies they will have bought at an Enroll America Free-Bagel Health Care Event!)

  13. Banger

    All this was crystal clear at the time the ACA was passed. The R party attempted to critique the bill since the left largely supported it but they were ignored. The details reflect the whole–it is a bill straight from the Mad Hatter’s Tea Party. It perpetuates a system that will do little to contain costs or reduce the systemic fraud currently in the system though some individual reforms are helpful–it perpetuates the actors that make our system the worst in the world as a system.

    To force minority youth or any youth who are already burdened to support such a rotten and nasty system is wrong. They aren’t paying for older people to get better they are paying for profits for the industry that does what it can to make sure we are all more stressed and thus get sicker and need more overpriced stupid drugs to make us dumber.

    1. Lambert Strether Post author

      The left supported single payer. Democrats and career “progressives” — not the left — imposed a news blackout on single payer news and censored and banned single payer advocates. That’s why the Overton Window hasn’t moved left on this, and that’s why single payer is still not on the table, despite its proven feasibility, cost savings, medical, and ethical advantages.

      See the first note. ObamaCare really is a medical experiment without informed consent; that’s the consequence of the suppression of single payer advocates. In the medical profession — although not, of course, to career “progressives” — that’s wholly unethical.a

      1. Banger

        It depends what you call “the left” I guess. Here I’m not speaking of the small band of real social democrats and socialists but of the nomenklatura of the left-wing of the Democratic Party. These people did, in theory, favor some variant of a sane HC system, of course–everyone that isn’t either just cruel or favors oligarchy knows the system is completely screwed up–as I usually put it–it is a system run with square instead of round wheels. Yet, these people, in the press, in government, in the consultant community, in the blogging community (DKOS) believed that it was impossible to convince the American people to accept a sane policy and that they feared that the criminally-minded people in the industry would blow such an attempt at reform right out of the water unless they made a deal with what is, essentially, organized crime.

        Thus they surrendered, grumbling, without even trying to push for real reform hoping that they could “fix it” later–I won’t get into that other than say that was BS. Yes, many on the left were deeply unhappy but, in the end, most supported the ACA. Why? Because this aforementioned nomenklatura is, as I know you know, not even remotely on the left–it is the equivalent of the phony Stasi-left–controlled by the very forces it pretends to oppose. I personally am convinced that a full-out battle for some variant of single-payer would have won the day–it would have taken at least an extra year to get a decent bill out the door but the truth of the matter is so obvious and so unmistakable that the right-wing crusade to battle “socialism” would have foundered because the supporters have no argument at all and, over time, that would have become obvious. Other right-wing causes may be noxious but they have rational arguments, at least on the surface–the argument to maintain the current system has nothing, zero, nada, to recommend it whether you are a socialist or a libertarian–in fact the gov’t already spends a huge amount on HC through Medicaid, Medicare and VA. The U.S.G. spends as big a percentage of GDP on health-care as any other developed country–so that can’t please libertarians, for example and the fact it doesn’t cover everyone doesn’t please social democrats. Why are we at this juncture–not bad policy but criminality in the industry, in the mainstream media that refuses to discuss the issue and both political parties who have to take care of the Barons first and argue over the scraps for the rest of us.

        1. Lambert Strether Post author

          I disagree on “believed that it was impossible to convince the American people to accept a sane policy.” The tell of bad faith is censorship and banning. These guys could have done their incrementalist thing and let us push single payer, so we’d all be in a better position for the next round. As it is, the policy universe is constrained to tweaking ObamaCare or abolishing it, and there’s really no way forward to a universal system. I mean, what can you do with people who are going all triumphalist about a system that gets 7 million more people covered after being in existence since 2009?

          Adding… I agree on the nomenklatura. I just think they’re even more intellectually corrupt than you think.

    2. John F. Opie

      It is working as designed. Remember that when the apologists try to pass off all exploitative and damaging effects as something no one could have foreseen.

      It is designed to enrich the management and owners of the medical system in the US (including “insurance”) at the cost of the consumers. Rent-seeking at its most pernicious.

  14. Sam

    I’m all for putting the United States middle class first. Not the banks, the coporations, the offshore accounts, the Chinese, Big Oil, the military industrial complex. The United States middle class. The jobs that have been sent offshore, and lied about, represent the loss of health care benefits. The United States middle class slowly woke up to that as of the poll taken last November 6th. Mitt Romney didn’t just lose, thanks to Jimmy Carter’s grandson and the hidden camera, Romney’s campaign was over in September.

    1. Lambert Strether Post author

      I reject the “middle class” as a sloppy and ahistorical analytical tool, and as an implict “suck up, kick down” morality. Whoever said “Nothing but the best for the workers” (I may have mangled the quote) got it right.

      1. Nathanael

        “middle class” == professionals, academics, middle managers, and small businesspeople.

        The middle managers are really different from the other three groups.

  15. MarioPa75

    Why all this overthinking about which system is best? Why don’t we just consider the following: eventually, you (yes, you) are going to need medical attention and treatment, no matter how healthy you lived so far.
    If you are young, even if you probably don’t actually think you are immortal, you act as if you know you are. Sooner or later any person close to you will make you an involountary witness of how the healthcare systems actually works and why you actually badly need a fantastic one. Nonenetheless you’ll pretty much remove any tought about it (even thinking about dentists make people unconfortable) because more often than not it’s laced in pain, uncertainity, doubt and financial disaster.
    You needn’t hit 80, pretty much at the age of 40 (or sometimes a lot earlier) you’ll have had enough experience to see why free healthcare is far more fundamental than anything else you think you need or wished you had for free.

    1. JTFaraday

      Yeah, that’s why the producerists did all they could to ensure that it only went to the workers.

      They’re nice like that.

  16. james

    obamacare to me is like the many scandals no body know anything when asked on the scandal… i don’t know… i don’t know! well how did they pull off obamacare and as law for no one who knows anything? i don’t know.. is that the answer?!families will go under… i do know!

  17. Anon CowHard

    Lambert Strether? Really? Geez, my respect for you guys has dropped 90%.
    This guy isn’t a principled truthteller, he’s just a bitter PUMA dead-ender who’s been hating Obama longer than Alan Keyes has. I thought you were asmarter than that.

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