ObamaCare Staggers Toward the October 1 Finish Line

ObamaCare’s capricious lack of fairness is, I think, a subject readers are now familiar with. Clearly, a program as big as ObamaCare will help some people; my beef is that ObamaCare, by virtue of its system architecture, will not and cannot treat all people equally, as single payer Medicare for All would do. People will be sent to Happyville or to Pain City randomly, and not when buying flat-screen TVs, but when buying a complex product costing many thousands of dollars that may (or may not) prevent bankruptcy or save a life. Moreover, ObamaCare’s system architecture, in consequence of Obama’s decision to preserve and protect the rental streams extracted from the body politic by the private health insurance industry, is needlessly complex, resulting in requirements abandoned and deadlines slipped, as is normal when a bloatware software project goes out of control. It may be that Obama’s public relations machine and career “progressive” enablers will be able to paper over these issues during ObamaCare’s launch phase, but they will become increasingly evident to the general public forced to enter, mandated to enter, the ObamaCare “marketplace” (the Exchanges). Whether what the general public experiences matters to policy makers is another question, of course.

So this week I’d like to take a quick survey of major ObamaCare implementation issues: The state of the California exchanges, the Pruitt v. Sebelius case, and whether ObamaCare will “make projection” and sign up 7 million people.

First, California. As is, again, typical with out-of-control bloatware projects, Covered California (the ObamaCare Exchange, or “marketplace”) is considering slipping its launch date; the euphemism is “soft launch.” LA Times:

Thursday, the state’s new health insurance marketplace said its website may not be fully operational Oct. 1 when consumer enrollment begins under the Affordable Care Act. But officials said they would know more after the results of key computer tests early next month.

This is, let us remember, 37 days from launch. For a complex system with potentially 7 million users (albeit with the more modest goal of signing up 1.4 million). This is insane.

We have not made that call yet,” said Peter Lee, executive director of Covered California, which is implementing the federal health law in the state. If online enrollment isn’t immediately available, Lee said, there would be other ways to sign up through call centers, enrollment counselors and agents before coverage kicks in Jan. 1. “The date we care about is Jan. 1 when coverage takes effect.”

I don’t care about the deadlines I can’t meet either.

Keith Ketcher, an outside project manager working on the state computer system, told the Covered California board Thursday that “there is work that remains to validate that the enrollment process is ready to go in October.… We will know in the coming weeks what our progress is.”

Well, 37 days is 5.28 weeks so yes, I guess you will. And of course people will be able to sign up on paper (Lee can’t seriously believe people are going to sign up over the phone), but how that will play with the youth Obama’s data geeks hope to attract is unknown,* and I’d bet they won’t do anything if they can’t use their cellphones or, heaven forfend, Mom’s laptop.

Meanwhile, Covered California is also shedding functionality, again typical of out-of-control bloatware projects. Sacramento Business Journal:

Covered California has decided not to include a quality rating system for health plans when the new insurance marketplace kicks off enrollment in October [and to delay this system until 2015]. …

But efforts will be made to post a couple of measures that health plans already report as soon as possible in cases where the provider networks for Covered California have at least an 80 percent overlap to current ones on the market.

So much for the idea that The Exchanged citizens consumers will be able to compare plans easily, like buying a flat-screen TV!

If ObamaCare is a political campaign — and by “if,” I mean “since” — then Covered California is Super Tuesday. Here’s a big state, committed to the program, where the Democrats are dominant, where the Democratic apparatus has a ton of walking around money to promote the program, and where the coveted Hispanic vote is huge. So Obama has to win California or, more precisely, be seen to.

Next, the Pruitt v. Sebelius, where the state of Oklahoma has unexpectedly been given standing to go for ObamaCare’s jugular. Here’s the theory of the case, developed in part (you will note) by the Cato Institute. (What’s the matter, ObamaCare is Heritage’s plan, so that’s why Cato has a problem with it?) From a Social Science Research Institute article by Jonathan H. Adler and Michael F. Cannon:

The Patient Protection and Affordable Care Act (PPACA) provides tax credits and subsidies for the purchase of qualifying health insurance plans on state-run insurance exchanges. Contrary to expectations, many states are refusing or otherwise failing to create such exchanges. An Internal Revenue Service (IRS) rule purports to extend these tax credits and subsidies to the purchase of health insurance in federal exchanges created in states without exchanges of their own. This rule lacks statutory authority. The text, structure, and history of the Act show that tax credits and subsidies are not available in federally run exchanges. The IRS rule is contrary to congressional intent and cannot be justified on other legal grounds. Because the granting of tax credits can trigger the imposition of fines on millions of individuals and employers, the IRS rule is likely to be challenged in court.

The 31 states that have not built Exchanges default to the Federal Exchange. That’s the back-up plan. So if the Federal Exchange can’t give citizens in those states their subsidies, ObamaCare’s back-up plan collapses in half the country. Oopsie.** Timothy Yost, an ObamaCare supporter, explains the mechanics of the PPACA bill, and the implications. Oklahoma’s Attorney General Scott Pruitt*** brought suit using Adler and Cannon’s theory:

[The Pruitt] plaintiffs challenge the Internal Revenue Service’s interpretation of the language of the ACA. Section 1311 of the ACA creates and defines the responsibilities and powers of the ACA’s exchanges. … Section 1311, and Congress in drafting section 1311, assumed that the exchanges would be established and run by the states in most instances. …

In fact, however, under our Constitution, Congress cannot require a state to establish a regulatory program. Recognizing this, Congress adopted section 1321 of the ACA, which provides that if a state fails to create the exchange “required” by section 1311, HHS shall create “such exchange” in its place. The term “exchange” is defined in the ACA as a “1311” exchange, and it is clear that Congress intended the federal fallback exchange to take the place of and fulfill all of the functions of the state exchange.

One of these functions is to determine eligibility for premium tax credits. Section 1411 of the ACA requires HHS to determine eligibility for premium tax credits based on information provided by applicants through the exchanges. Section 1401 creates a new Section 36B of the Internal Revenue Code, requiring the IRS to provide premium tax credits to individuals determined eligible. In promulgating rules under its statutory authority to implement section 36B, the Internal Revenue Service has determined that premium tax credits are available through both the state and federal exchanges.

Section 36B(b), however, provides a formula for determining the amount of the premium tax credits. In this formula, the section refers to premiums paid and months of coverage of persons enrolled in a qualified health plan “through an Exchange established by the State under 1311.” Opponents of the ACA have seized on to this phrase to claim that premium tax credits are only available through the state exchanges and that the IRS rule is contrary to the statute and invalid.

Well, I’m no strict constructionist, but these guys “seized on to [sic] the phrase” because — follow me closely, here — they actually read the text of the statute carefully. And the idea of the Courts, in essence, redrafting legislation because “everybody knows” what the legislators “really meant” strikes me as more than a little iffy. Does the Executive branch get to do that too? And in secret? Yost goes on to point out what are from his perspective bad policy outcomes, but those are not, or should not be, relevant to the Court’s decision. Picking up the thread:

Clearly [these bad outcomes are] not what Congress intended. … In the voluminous records of ACA debates, there is not the least suggestion that Congress did not intend federal exchanges to issue premium tax credits, while there are many references to the fact that premium tax credits would be available in all states. Indeed, it was not until late in 2010, months after the ACA was adopted, that the possibility that only state exchanges could issue premium tax credits was first noticed.

Yost goes on to describe how Judge White gave the state of Oklahoma standing, since they’re employers who would be “concretely injured” by the IRS”s decision, in that they’d come under the employer mandate (which is pretty hilarious argument). Then:

In sum, the Oklahoma case is likely to reach the merits of the challenge to the IRS rule. It will do so, however, before a judge that seems skeptical of the claim that the state of Oklahoma has been injured in some way by the IRS’s decision to ensure that its residents receive premium tax credits. In his opinion, Judge White also described the article by Michael Cannon and Jonathan Adler setting out the theory on which the state bases its case as “polemical law review article.”

Not that there’s anything wrong with that! Bottom line is there’s a big monkey wrench flying through the air aimed directly at some even more rickety than usual bits of ObamaCare’s Rube Goldberg-esque machinery, but nobody knows whether it will hit or miss. Pass the popcorn.

Finally, will ObamaCare make projection? From a USA Today survey of state projections:

Estimates from 19 states operating health insurance exchanges to help the uninsured find coverage show that at least 8.5 million will use the exchanges to buy insurance, a USA TODAY survey shows. That would far outstrip the federal government’s estimate of 7 million new customers for all 50 states under the 2010 health care law.

USA TODAY contacted the 50 states, and 19 had estimates for how many of their uninsured residents they expect will buy through the exchanges. About 48 million Americans were uninsured in 2011, according to the Kaiser Family Foundation.

Well, this is interesting; the states running their own exchanges (not the ones who opted out) could put ObamaCare over the top. Of course, since the ObamaCare rollout is a political campaign, and the biggest states (California, New York) are Democratic, that is exactly what we would expect them to say. (You don’t hear “My guy’s gonna lose” a whole lot from party apparatchiks before election day, do you?) So it would be nice to have actual polling data on this point. However, the tactic of managing expectations by lowballing is an ancient one, and again, the ObamaCare rollout being a political campaign, we would expect the administration to have used it. FWIW, my take is that the administration will pass the 7 million bar, and lost in the Hossanahs and confetti and pom pom-waving will be the pathetic fact that 41 million Americans will be uninsured, and roughly half of those will still be uninsured when ObamaCare is fully implemented. After LBJ rolled out Medicare for all over-65s in just one (1) year. So, modified rapture.

NOTE * It’s important to attract youth to ObamaCare for actuarial purposes, so that the healthy not-yet-old subsidize the sicker no-longer-young. Why the Department of Health and Human Services has decided to adopt a business model from private health insurance baffles me; this is cognitive regulatory capture of a very high order. Why not focus on those who need care, instead of those who don’t?

NOTE ** Of course, if the Democrats had abolished the filibuster in 2009 and passed single payer Medicare for All (HR 676, SB 703), establishing a uniform system across the entire country, none of this would have happened. Unfortunately, the administration was more concerned to preserve the insurance industry, its rents, and its campaign contributions (and its career opportunities). So much for that.

NOTE *** There is a Halbig case as well, but apparently it’s unlikely to get standing, unlike Pruitt.

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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. charles sereno

    Now that the ungainly critter, Obamacare, is slowly revealing itself, might that not be an unexpected gift? Now that it is emerging from behind the Lobby-land of Congress and the President, it is much easier for the public to make a coherent, feature by feature comparison and argument for a Medicare for all, sngle payer plan modeled on the well regarded, real-life Medicare that they are already familiar with. While Obamacare may arguably be a bit better than the existing system, why settle for a reconditioned used car when a shiny new one is available at a CHEAPER price?

    1. lee

      You’d think at this stage it would be possible, particularly here in CA, to “make a coherent, feature by feature comparison” utilizing the state’s health exchange web site.

      I have been trying to do just that, comparing my 27 year- old’s current individual plan with those being offered on the exchange. Unfortunately the website offers details on the so-called Silver plan only, which is somewhat comparable to the plan he has now for an estimated 10% higher premium. I await further revelations.

      Given the high deductibles, co-pays and out-of-pocket costs of these plans, the twenty-something demographic should be a real money-maker for the insurance companies. Based on my own twenty-something’s devil may care attitude toward health insurance coverage, I foresee compliance issues ahead.

      The only reason my twenty-something has health insurance is because I pay for it. I pay for it because if push came to shove I would reduce myself to penury in order to keep him alive.

  2. ex-PFC Chuck

    “Next, the Pruitt v. Sebelius, where the state of Kansas has unexpectedly . . “

    Lambert, did you intend to write “Oklahoma,” or is Kansas somehow also involved in the case also?

      1. heresy101

        Thanks for the background on the “Public Option”.

        A suggestion to avoid falling into the false Demo/Repug debate would be to not call Obama’s gift to the insurance industry as Obamacare. Even though it is longer, Obama’s sop, as it truly is formulated, should be called what it is: “Obama’s implemenation of Romneycare”. It will be easier to promote single payer when Obama’s implementation of Romneycare fails. The right won’t easily be able to claim the moral superiority because they opposed “Obamacare”. Single payer will be more easily posited.

            1. Emma

              ObamaCare is no surprise as it’s simply the democratic segregation of constitution, isn’t it?

          1. Ms G

            PPACA = Obama’s InsuranceCompanyCare

            ObamneyCare works well too, though “Obamney” has become cliche’d through heavy use (which is in no way a bad thing) and thus has a way of slipping into the part of the brain that just registers a cliche without lights going on …

            My .02!

        1. Lambert Strether Post author

          Adding, that background on the so-called “public option” is really important because it shows the methods the career “progressives” used to run interference for Obama and suck all the oxygen away from single payer. In other words, if I have what are called trust issues with these guys, there’s a reason for it. If they had allowed single payer to be part of the discussion, we (especially those who need care) would be in a much better position today when ObamaCare starts showing its many limitations. We would have a clear alternative already in the discourse, “at the table.”

          And the career “progressives” and nobody else prevented that; they didn’t even give single payer oxygen in the blogosphere. That really tells you all you need to know.

          1. sd

            During the 2008 campaign, Krugman regularly railed about the lack of discussion of expanding Medicare. Krugman favored Clinton specifically because she was at least acknowledging Medicare was out there – for instance, expanding coverage to anyone 55 and over.

            Obama’s position was always identical to Romney’s. Why so few could see that was beyond me.

            With Hilary at the state department, she couldn’t use the Senate pulpit to challenge Obama on policy.

            1. JTFaraday

              If I recall, Obama’s initial position was that health insurance was “house insurance,” and people with no assets to speak of didn’t need to spend money they don’t have to buy insurance to protect the assets they don’t have either.

              But if Obama had stuck to that line, he wouldn’t be President today. And this is not the Romney position. The Romney position is that people without assets should indeed buy insurance to protect the assets they don’t have with the money they don’t have either.

              As for Krugman, I certainly never read him with any degree of religious fervor, so I may have missed his passionate advocacy of medicare for all, but every time I tuned into Krugman he seemed to be beating the drum of “irresponsibility.”

              In short, it was “irresponsible” for people with no assets to protect not to buy insurance to protect them, because emergency rooms would get up hit with outrageous fees by their own billing departments. Or something. And these outrageous charges would devolve on the collective.
              Therefore, the universal mandate to purchase insurance was the only morally sound.

              It’s at that point that I decided that all pundits should have to report their assets and holdings to the public just like politicians. In detail.

              In my observation, it was Krugman who shared the Romney forced purchase position. Obama, albeit flippantly, did say something else.

              1. JTFaraday

                oops. That should say:

                the forced purchase mandate was the only morally sound position.

                sorry about that one.

                1. JTFaraday

                  All of which is just a way of saying that the hypothetical hit to the property of others posed by the uninsured person who may (or may not) need healthcare justifies a pre-emptive strike by the state against the property of the uninsured person in the form of the forced purchase of health insurance.

                  And this is morally justified whether or not those uninsured people have assets in the first place. There’s nothing remotely fair about pre-emptive takings when people are struggling to keep body and soul together in the first place.

                  Krugman is a neoliberal tool.

                  1. Alexa

                    Hear, hear, JT.

                    Personally, I wasn’t blogging during the 2007-2008 Presidential election, but I was very strongely against a “mandate.”

                    It will be interesting to see, now that this Administration is systematically “restructuring” the original ACA–basically giving preferential treatment to corporations (or business) over the average guy–what the supporters of a mandate will think about this policy, in a few years.

                    I expect what happened to “working” United Parcel Service (UPS) spouses, to continue.

                    This policy has been in effect in Mr. A’s company for several years now.

                    Just watch the attitude toward the mandate go south, when individuals who were supposed to be allowed to stay on their employers group health insurance plans, get thrown into a Health Exchange (or the Marketplace, whatever).

                    And if the Dems lose in 2014 and/or 2016, I would not be surprised to see the “subsidies” go unfunded (i.e., disappear), but the “mandate” stay in effect.

                    Sadly, since so many of the Democratic Party Base seems only capable of functioning as “door mats,” it is almost impossible for me to envision MFA.

                    I hope I’m wrong. ;-)

  3. TK421

    “Contrary to expectations, many states are refusing or otherwise failing to create such exchanges”

    Ha ha ha! Yes, who would have thought that Republican-led states would decide not to go along?

    1. Lambert Strether Post author

      You got it! Nobody could have predicted that the party that impeached Clinton over a ******* would fail to cooperate with Obama!

      In other words, it’s kayfabe all the way down.

  4. Yancey Ward

    Why the Department of Health and Human Services has decided to adopt a business model from private health insurance baffles me; this is cognitive regulatory capture of a very high order. Why not focus on those who need care, instead of those who don’t?
    Read more at http://www.nakedcapitalism.com/2013/08/obamacare-staggers-toward-the-october-1-finish-line.html#FUxP7Z1Ax0m9rAeE.99

    There is no mystery here, Lambert. The system was adopted because your alternative would have required funding 100% via taxation rather than the funding through various mandating procedures. Democrats in 2009 could have, of course, simply ignored budget rules (instead of messing with the filibuster directly), and added the entire cost via deficit financing, but they also freely chose to not do that either. Democrats chose what they chose because they thought they could fund it mostly through illusory cuts to some programs, a smattering of higher taxes (some of which probably will be waived until the apocalypse), and mandates on companies and individuals (some of those likely to be waived repeatedly or simply never collected). In the end, most of the cost is likely to be added directly to the deficit, which would have argued strongly for the abolition of budget rules in the first place if one were intent on enacting universal care.

    1. Ms G

      The Democrats’ shameful support of ACA can’t be summarized in a post. As to whatever rationale they used to be able to wake up in the morning and look at themselves in the mirror — e.g. cutting things here and there, raising taxes here and there — one of the gimmicks they fully supported was, get ready for this one, a 2.5% Tax Increase on the 1040 medical expenses deduction, in the form of raising the thresshold for the deduction to 10% (from 7.5%).

      The people who most need the medical expenses deduction are either the uninsured who pay for services and pharma out of pocket or the self-insured (who are captive in the overpriced cartel private insurance market). And guess what — these are precisely the demographic that Obama claims that PPACA is supposed to “help” by making insurance more *affordable.*

      So the Democrats’ sell-out as reflected in this particularly glaring detail was deliberate, knowing and nasty, despite stories they told themselves that this FrankenProgram would be “balanced” with unrelated bits of legislation “here and there.”

      So I want to thank the Democratic Leadership and Mr. Obama for the 2.5% tax hike that ObamaCare has delivered to me and many others — in the name of “Affordable” and “Universal” health care, of course, which makes it all the more odious.

      Rant over.

  5. LillithMc

    Medicare for All would put most health care organizations out of business if done right now. There is a reason our costs are double that of the rest of the world. Many on medicare have difficulty finding health care that will accept them. Obamacare is an interim step between millions getting health care they need and going back to the bad old days of 50 million or more without health care especially since so many red states are refusing to work with medicaid.

      1. Yancey Ward

        None. It is hard to even think of politically possible fixes, either:


        Ask yourself why single payer/Medicare for all basically had no strong advocacy in 2009, even with Democrats in a strong position? The reason, of course, was that such ideas require explicit funding via taxation, and Democrats have promised universal care that basically will cost it’s consumers nothing. PPACA was the best they could do to hide the costs involved.

        1. Lambert Strether Post author

          If the Democrats had passed single payer in 2010, and assuming, like Medicare, it took a year to implement, we would have already have saved a trillion dollars.

          All tbe budgetary manueverying is kayfabe to allow Obama and the Democrats to do what they always wanted to do: Allow the insurance companies to extract rents from the body politic forever.

          Of course, forcing people into a market is also a bonus. The conservative critique is to ask: What is the next market people will be forced to join? I agree with them.

      2. Code Name D

        Ah yes, the argument that Obama’s Romneycare program is some how intended to fail. And when it fails, the free market approach will be completely discredited and the way will be made open for universal coverage.

        It’s hilarious to watch the apologist’s argument take on a life of their own. This is an argument that even Obama has tried to squash. No, he truly intends the ACA to be the final solution to America’s healthcare problems. He has dedicated a substantial amount of time speaking – and writing about how he is convinced that the free market approach will work.

        1. Lambert Strether Post author

          I have never seen a single bit of evidene for this “11-dimensional chess”-style theory by Obama apologists.

          And I’d love it, so I could give it the shredding it deserves.

    1. Ms G

      Well, a lot of the businesses that would go out of business if Obama implemented Medicare for All today deserve to be out of business(*) as they are part of the intermediary class of rent seekers that inflate the cost of health care to the Milky Way and render it inaccessible to tens of millions of Americans who have done absolutely nothing wrong in their lives except refuse to rob banks to have enough cash to pay for the Intermediary Rent Fee Add Ons caused by “a lot of the businesses.”

      As well, if Medicare for All were implemented you would be surprised how many doctors and hospitals would suddenly be accepting Medicare all of a sudden.

      (*) This would not be the first time that an entire sector of the economy was erased by Government fiat. See, e.g., NAFTA and the practically overnight destruction of industrial economy and jobs in the United States. Sadly, in the case of NAFTA, the jobs and sector that were destroyed actually contributed value to the economy (and good salaries and benefits). The problem for the Elites was that it just couldn’t be tolerated anymore that producing value in the U.S. economy should be rewarded with decent wages. With the Health Insurance Intermediation Sector, there isn’t one job that contributes value except for that it props up the predatory cartel of the “health” insurance racket.

  6. Yancey Ward

    Two other things:

    (1)The Pruitt case will fail. The courts will eventually simply interpret the subsidy clause to cover both of the sections describing the two types of exchanges. And, even if the Pruitt case succeeds, it will be at least 2 or more years before it is fully decided, and other events are likely to undo the law before then;

    (2) I also think HHS is low-balling the 7 million number. The problem will be that, even if they hit a higher number, it will be the distribution of the buyers that will explode the exchanges regardless. Only people who will net benefit to an extent greater than their costs will buy the policies, while those who won’t net benefit will refuse to provide the subsidization that is required to keep the system stable. That is where the program will end up partially defunded.

    1. Lambert Strether Post author

      I think Pruitt will fail also, but it’s still something to watch and maybe they’ll figure out if it’s possible to shop for a friendly judge.

      On the 7 million, yes, that’s why basing the system on actuarial value will fail. There’s also a certain schadenfrueude in watching Obama devolve from selling hope and change to selling junk insurance — to the same population that put him in office in 2008. There’s a lovely symmetry there.

      1. katiebird

        Some of them get the junk insurance, some get the cash:

        How Obamacare Makes Theft Of Your Identity More Likely

        It seems as if every day brings a new Obamacare disaster—missed deadlines, soaring costs, unintelligible bureaucratic requirements. Now add the risk of potential rampant identity theft to the list. Last week, the Obama Administration doled out tens of millions of dollars to “community groups” across the country, with few strings attached. These groups — and those posing as them — could gain access to consumer addresses, Social Security numbers, and medical information. It’s the President’s gift to some of his grassroots allies. And it could be a bonanza for identity thieves.

        It’s all part of the so-called “navigator” program, where community groups will take to the phones, streets, and hospitals to sign people up for Obamacare. But in its rush to get this taxpayer-funded marketing scheme off the ground, the Administration left consumer privacy behind. Federal regulations governing the program don’t require these groups to do background checks to weed out criminals and would-be identity thieves. Nor do they need to be licensed, bonded, or insured– though they may choose themselves to take these steps or perform background checks

        1. Lambert Strether Post author

          37 days to launch, and they hand out millions of dollars to political allies? That’s not serious; programs like that take time to plan, train, create collateral.

          It’s pure walking around money, case closed.

          It’s corrupt.

          * * *

          The collapse of the Republican party is no more evident than in the ways they refuse to call bullshit on what’s really wrong with ObamaCare. This is a friggin’ no-brainer, and nobody makes the call. The feral, savage apparatus under Rove would have done much better.

          It’s sad, really. It’s like watching Al Davis’s Oakland Raiders devolve into a bumbling third-tier team.

      2. Ms G

        “There’s also a certain schadenfrueude in watching Obama devolve from selling hope and change to selling junk insurance — to the same population that put him in office in 2008.”

        Exactly. And how many people would even by a used car from the guy (unless held at gunpoint)?

  7. Cloud

    Got to Thoreau this noise.

    It’s just another few layers of incomprehensible paperwork that I will never deal with because life is too short for this shit.

    Sure I may be entitled to government handouts hiding in some labyrinth, theoretically and nominally; but who has the wherewithal to perform the necessary rituals and incantations to access them? Am I the only one who curls up in a ball of despair when faced with these things?

    The existing 20th-century structures (e.g. figuring out a W-2 from a W-4) are hard enough for me. This shit with its 21st-century standards of incompetence and rentier lock-in? Forget about it.

    1. Yancey Ward

      I also think this problem has been given far too little attention in the design of this program. Who really thinks all the aides being hired to help with this won’t be just a bunch ignorant temp hires who won’t actually help anyone navigate the complexity?

    2. Lambert Strether Post author

      If the Republicans — and the conservatives — were serious about opposition, they’d be talking tax resistance. After all, “Taxes ZOMG!!!!!” is their stock in trade, right?

      Instead we get the ludicrous spectacle of peurile “conservative activists” [seeking wingnut welfare by] burning their ObamaCare “registration cards,” or campaigns to get people not to sign up! Which is nutso, truly nutso, because ObamaCare is going to benefit some but they’re trying to keep it from all. No concept of goverment and politics providing concrete material benefits whatever.

      What the Republicans really need is a Disraeli who could steal the Democrat’s clothes. Never happen, alas. So we get the current clown show of the parties beating on each other with foam bats.

      1. Code Name D

        I think the Republicans are smarter than that. I suspect that their resistance is mostly for show. They don’t really expect to overturn ACA, but rather what they are doing is putting their opposition down on the record. They then plan to simply step out of the way, and let this train wreck run its course. They will then be there to pick up the pieces. The classic rope-a-dope strategy.

        I suspect the reason why they decided not to attempt to defund ACA is that this would be counter productive, it sets them up for taking the blame when ACA inevitably fails.

  8. elboku

    I just have to say this (and I know I will be crucified here for it) but if even one person gets health insurance who did not have it before, I am happy with the ACA. I worked with MS for quite a while and could not find insurance that was even remotely payable. In MA where I lived and insurance had to cover you, they quoted me 3 thousand a month for the cheapest insurance coverage. So I went without until I became so sick I got on disability and get Medicare.

    And I one hundred percent believe and always have believed that when we are born, we should be handed a universal insurance card free of charge with no deductibles and no limitations. I paid huge taxes as a lawyer who was self-employed and did not begrudge a dime. It is our duty as human beings to take care of each other. Period.

    Does the ACA blow in how it does things? Heck yeah. But let me tell you, I cried when I got insurance and I am sure those who get insurance for the first time or get it back will cry also. There is no way to describe your life when you are uninsured, sick, and without hope.

    1. NotTimothyGeithner

      Do you think the people who lost their insurance because of ACA cried with joy for your news or sadness for their news?

      At some point, the “I’ve got mine to hell with everyone crowd” mantra gets a little old.

    2. danb

      Lambert in this series has documented how Obamacare makes needless unfair distinctions, sending some to pain city while a few benefit -as long as the insurance industry controls the $ game. Your case proves his point. And if Obamacare is unsustainable as a system, then how long does your benefit last anyway?

    3. katiebird

      Well, as Lambert points out right at the top, some people (randomly) get sent to Happyville and it seems that you might be one of the lucky ones. But, what makes this law evil is that lots of other people (randomly) get sent to Pain City.

      And me? I think that if even ONE PERSON gets sent to Pain City as a result of this law, that makes terribly Unhappy.

      It’s astonishing that anyone could profess happiness with this law when we should have had the votes for expanded Medicare for Everyone and it could have been implemented in January 2010.

    4. Lambert Strether Post author

      Yes. It’s especially repellent that ObamaCare apologists then take the people who did get covered hostage for the program as a whole, and then use emotional blackmail to distract from the millions they’re still throwing under the bus. (ObamaCare, even when fully implemented, will not cover about half of those currently not insured.)

      Why don’t they want everybody to have the same level of care that some do?

      1. elboku

        Did you even read what I wrote? I support single payer period. Always have. Always will. No one is disputing that there are people left behind. That sucks. Blows. Is evil. Whatever you want to call it. I agree.

        My point is some people are getting coverage and it will change their lives. That is a good thing. You can say it isn’t and scream about the unfairness as I did, do, and will. But your failure to acknowledge that some people will be helped is inane and insane.

        Why we don’t have universal coverage in the US is pretty clear and obvious to any sentiment being. Too many of us don’t give a rat’s ass about anyone else. That is sad but true. I saw it while working as a children’s advocate and see it today.

        I see this as a convoluted step in the direction of single payer and universal coverage. It is insane that I had to get sicker and sicker to the point of being disabled totally BEFORE I could any help. If the ACA was in place when I was working, I could have afforded my meds and gotten the care I needed for my MS. I would have continued to pay the staggering taxes I did to support this country. But, no, even in a progressive state like MASS., I was s.o.l.. So now, the ‘gubmint’ pays outrageous sums for me that maybe, just maybe could have been avoided.

        If you don’t see the benefit in that; well, you are being willfully blind and obtuse. I want coverage for all from birth. It is the moral thing to do. I am not apologizing for the ACA- I did not write it the bill and didn’t support it. No one hates insurance companies more than I do; both from being a lawyer having to deal with them to being a person injured who had to deal with them.

        Yes, I am unhappy that even one person suffers under this bill- who isn’t? So, what should we do? Make everyone suffer? Yeah, that is moral and makes perfect sense. I would rather fight for single payer and to eliminate insurance companies; while knowing at least some people are getting help.

        You want single payer faster? Eliminate the employer health insurance subsidy. Watch people go nuts and demand insurance for all ASAP. We would have national health in a year or so.

        1. Lambert Strether Post author

          I not only read your comment, I know you didn’t my post, not even the first paragraph, where I wrote:

          Clearly, a program as big as ObamaCare will help some people; my beef is that ObamaCare, by virtue of its system architecture, will not and cannot treat all people equally, as single payer Medicare for All would do.

          [dusts hands]. Next?

      2. Ms G

        Apologists’ use of “Emotional blackmail.” Indeed.

        And, frankly, the “I cried” line (and quite possibly the “and I have MS” line) is typical of the sort of TV Ads that may be doing the rounds of Teebee or hyper-local media outlents. Which seriously raises my concern-troll antenna in this case.

        Bottom line, as KB and LS have reiterated, is that ObamaCare randomly selects winners for the Happyville Tour (though how long that will last is anybody’s guess) and losers for Sickville. It’s a system of
        Russian Roulette imposed by a US President (no less) on his citizens and (worse) under the guise of a “health care” program (forget the “affordable” part which would be funny except it’s really, really not.)

  9. JimZ

    While President Obama has signalled that he doesn’t object to the ACA being called “Obamacare,” let us not forget that the die for this corporate-oriented program was cast so early in the process when big pharma, big hospital companies and big insurance got to Obama and told him what it was going to take for them not to kill him (politically) over the effort. And when he acquiesced, the game was over and ObRomneycare wended its way to his desk. The rest, frankly, were mostly details that come with the implementation of any large, complex program whose basic structure is all about crony capitalism. The real question (way back then) was, how badly did the President want a bill? Industry saw how desperate he was, and thus the form of the current law. The big question going forward is, will future congresses, presidents and most of the powerful special interests (I deliberately leave out ordinary Americans) make sufficient deals to mold the program to eventually extend servcies to more people, at fairer costs, and under a much more efficient framework. One can always “hope.”

    1. Banger

      I think your characterization is correct. Obama is subject to whatever the power-elite feel needs to be done. Clearly the power-elite did not want a real reform of HC but certainly wanted the issue defused. They were able to control the information and the “debate” by keeping all rationality and science out of the discussions–it was all about the horse-race.

      But, we have to understand that the average person doesn’t care that the U.S. is now nearer to the undeveloped countries along a number of metrics than it was a few decades ago. We are, collectively, rather indifferent to almost everything.

      Having said that, it is possible that the considerable number of people within the HC profession may be able to make a semblance of lemonade out of this strange brew–I believe they will give it a try. We’ll see. Certainly part of the industry is not interested in anything but maximum profits and maximum human misery.

      1. Yalt

        Well, maximum profits require that the system not fail so totally that it’s abandoned altogether. So there’s that….

  10. Benedict@Large

    Don’t settle for Medicare For All. Get rid of the insurance model entirely. Deductibles and co-insurance are relics of the 1950s, and have no place in a modern healthcare contract. The only function they have today is to ration healthcare by excluding poor people with insurance from using their insurance.

    1. Ms G

      Absolutely correct, and something that we can’t lose sight of if we’re advocating Universal Health Care for Americans. Though the Medicare for All slogan has the merit of recognition as to a system that is in place and (sort of) works — except co-pays, co-insurance, the death-by-1000-cuts hollowing out of care provided and providers who accept it. (Not to mention lack of dental care which, apparently, was an “accident of history” in the form of the dentist lobby who did not want dentistry to be in Medicare — and they won.)

    2. Yalt

      25 years ago I was working for the in-house PPO of a major university. The plan we had in place for employees was pretty simple: no deductibles, no copays except for $3 per month per prescription. Specialty treatment required a screening referral from your primary physician to make sure you weren’t wasting someone’s time by going to the wrong place. Otherwise, as long as you were getting services in the university’s own hospital it was all free–not even a monthly paycheck deduction.

      The reason I bring this up is that we didn’t have a problem with overuse of the system (or even attempted overuse–our primaries weren’t overwhelmed with bogus requests for referrals). That’s the nominal purpose of copays and deductibles, they force the patient to have some skin in the game, to use the technical insurance term, and think through whether they really need the appointment or not.

      But in practice most people hate going to the doctor enough that that alone apparently serves the function usually performed by an insurance copay.

      The plan’s long since disappeared, of course. Once you’ve converted to the precariat-instructor HR model you don’t really have much need for this kind of excessive benefit.

  11. Joe

    I’m not sure if this is sincere journalism or just the NYT usual version of government butt kissing. It seems like the Times is just trying to scare the sheep into the holding pen for the fall shearing. Either way, it seems relevant to the topic at hand:
    How to Charge $546 for Six Liters of Saltwater

    “It is one of the most common components of emergency medicine: an intravenous bag of sterile saltwater.

    Luckily for anyone who has ever needed an IV bag to replenish lost fluids or to receive medication, it is also one of the least expensive. The average manufacturer’s price, according to government data, has fluctuated in recent years from 44 cents to $1.”

    1. Ms G

      … which, of course, has to do with private corporations (pharma and hospitals) gouging on generic things that cost a penny, like saline solution. Which problem — government price controls (like they have in every other first world country) — is most certainly NOT fixed by ObamaCare which, if anything, ably preserves this status quo.

      Any time you see an article about the insane prices of pharmas or med services near a mention about ObamaCare as some sort of antidote, it’s a DIVERSION and a SNARE to be dismissed out of hand.

      If we’ve learned one thing about ObamaCare at this point — notwithstanding the NSA-like secrecy in which it is operating — it’s that (1) it can still make you bankrupt (because it does NOTHING to control the prices of (a) insurance and (b) medical services and RXs — and the policies look to be ruinously high-priced lemons, and (2) conversely, it was crafted by and for pharmas and private medical providers precisely to maintain and GROW the out of control inflation of the goods.

      Plus NYT has been publishing stories about outrageous costs encountered by people at hospitals, but very little about the shaft that the *insured* patients are getting from their insurance companies in re those costs.

      NYT is part of the ObamaCare PR Campaign.

  12. myshkin

    For all their sophistication many commentors on this site seem to believe that the legislative process in the US, in this one instance is operating in a perfect vacuum that the legion of lobbyists and bought congressman are unable to penetrate, that Obama is not part of this troubling scenario and should and could snap his fingers and the sordid band of Republicans and Democrats and the entrenched industry will jump in line.

    In the messy, unfortunate world we inhabit, the cliché for the legislative process is sausage making, best not to consider the process, which conveniently seems to be the rationale here at NC, where they wait expectantly on the perfect bologna to emerge from the sausage maker.

    That the affordable health care act may actually have moved the issue an increment in the right direction should be countenanced as a possibility; it isn’t all or nothing, universal single payer or back to the frigging emergency room when you come down with the flu.

    Just not the way it works, particularly when it as thoroughly corrupt a process as is functioning in DC. If a civilized health care program emerges from this, (admittedly there is a good chance that the AHCA is so Rube Goldberg and sabotaged it will explode in Obama’s face and I wonder will the NC crowd be thrilled?) it will happen over ten to fifteen years.

    If the AHCA goes into effect and is expensive, congress will look for ways to economize and eventually some sort of rational program will evolve. Universal, single payer is the way to go but someone better locate the magic dust if you’re expecting it to emerge full blown from the head of Obama or any president we’re likely to elect in this country.

    It should be noted that there are other countries where every one is included and the insurance industry is heavily regulated and still part of the system. It should also be acknowledged that the more federal revenue entangled in non-discretionary, mandatory spending, like the the AHCA, the less available for US imperial projects and further, when a program like SS, Medicare or AHCA succeeed people take an interest in the programs and pay closer attention to what their elected representatives are up to.

    Not an Obama fan, don’t know where this is going but I can’t dismiss the possibility that something positive and not an absolute train wreck is further down the track.

    1. Ms G

      With regards to your comments about how ObamaCare is “the best one could have hoped for” given the “process” in Congress, I invite you to read Lambert’s numerous posts and comments pithily summarizing the true story of how Obama (and his army of “progressive” politicians and media pundits) squashed single payer outright and picked ROmneyCare as his blueprint because he likes it — not because anybody twisted his arm. And this, in a Congress where Obama had Dem majority in both houses and a mandate.

      Again, there are no better sum-ups of this sordid history than Lambert’s.

      Happy reading.

      1. myshkin

        I’ve been following the estimable Lambert’s writings on health care and share his anger just not all his and other commnenter’s conclusions.

        1. NotTimothyGeithner

          Um which comments? You haven’t addressed any points, and when you were confronted with addressing the numerous articles about the disaster that is Obama-care by Lambert, you run away. Isn’t that weird?

          1. myshkin

            “Um which comments? You haven’t addressed any points, and when you were confronted with addressing the numerous articles about the disaster that is Obama-care by Lambert, you run away. Isn’t that weird?”

            -Let me just say, I’m so glad you’re NotTimothyGeithner and you must be too.

            Weird? If you had been following Lambert’s series on the AHCA roll out, as I have, you might have noticed I posted on at least one of his previous critiques, more or less the same general objection I raise here, admittedly not pertinent to the crazy cuckoo clock mechanism that Lambert has been expertly disecting but still relevant to the big picture re: health care in the US.

            By the way, how did you know? My plan is to run away, as the Pythons of yore, but North to Canada, where a civilized health care plan awaits, not the fearsome killer bunnies found here on the pages of NC.


            You might take a look at the history of the health care plan up there and then reconsider what I have posted that you find objectionable. They have a province by province system that varies province to province, funded by the provincial and federal government. It’s a pretty good system at a fraction of the cost and a high percentage of Canadians are satisfied with it.

            I’d be curious to know how exactly you think a universal, single-payer health care plan will emerge from the shambles of the US political system. I think, if we’re lucky, it might start with something as broken as the AHCA.

            Good luck NotTimothyGeithner.

            1. NotTimothyGeithner

              Good more attacks, but you still haven’t actually addressed any issues that you raised.

              Why don’t you provide examples of your original complaints and explain why those are wrong? You have still failed to do this. This would be an example of running away.

              Are there better Obots out there?

              1. myshkin

                Sorry but what attacks are you talking about? I just briefly described the Canadian plan and that there is a history behnind it, a long one. And don’t throw that Obot shit at me.

    2. LillithMc

      Good comment, myshkin. I wonder why Obama attracts such amazing focus. Many in the US have been trying to reform health care for over 40 years. Some states already have universal access to health care. As usual the health care cartel has been able to control the game as was clear when Senator Max Baucus stalled a better House bill in his committee until his sponsors, the health care cartel, read and altered the Bill to suit themselves. This is standard procedure for Republicans with their ALEC bills passed in all the red states that are a revolution against the federal government and rights in the Constitution. Instead of writing about the power of the health care cartel, it is all focused on Obama who will soon be a private citizen. It is also possible that Obama understood what his Mother went through when she died without adequate care due to our for-profit system that is very accomplished in preventing care for the sick. Perhaps it is the forcing of medical care onto the tax returns that has people terrified. Any single payer system will also be taxed so don’t cry false tears for what never happened when we all know there was no chance for better than what we got until we put the billionaires, corrupt Congress and gang of 5 on the SCOTUS in their proper places meaning no longer in control of the most expensive discriminatory health care system in the world. Given that the illegally gerrymandered House has voted to repeal Obamacare 40 times and plans to take the Senate with both their partisan gerrymanders and voter suppression, probably we will soon be dying without health care in massive numbers which is the real Republican plan. They have already prevented 3 million poor from receiving care through their refusal to work with medicaid in many red states not to mention their closing of most health care clinics for women in all the red states leaving perhaps a token center open until they reverse Roe vs Wade.

      1. Lambert Strether Post author

        Well, that’s why the Democrats should have passed Medicare for All after abolishing the filibuster in 2009, or by reconciliation, bypassing the Republicans entirely. The Democrats completely own this policy outcome. If Obama and the Democrats had wanted to prevent the suffering of Mothers everywhere, that’s what they would have done.

  13. Paul Tioxon


    The Story Behind the Biggest Mistake in Obamacare

    The main purpose of the Affordable Care Act (ACA) was to provide health insurance for most of the tens of millions of Americans who don’t currently have any coverage. But after an impossible-to-predict move from the Supreme Court seemed to gut the law’s ability to do that, millions of people will instead get coverage through a drafting error that was never supposed to become law.
    Here’s the mistake: Under the ACA, Americans with an income below 138 percent of the federal poverty level qualify for Medicaid, the public low-income insurance program, starting in 2014. But at the same time, Americans with an income of 100 percent of the federal poverty level and above (up to 400 percent) qualify for federal tax subsidies to purchase private insurance on the health insurance marketplaces created by the law, which also open in 2014. Those are the two main ways that uninsured people are supposed to get health coverage under the law.
    The ACA stipulates that an individual can’t qualify for both Medicaid and a tax subsidy (as people between 100 and 138 percent of the federal poverty level technically would). To address that gap, the ACA said that anyone who qualifies for both would just automatically be enrolled in Medicaid. So why don’t the thresholds simply meet at 138 percent? Well, they were supposed to, but because of an oversight while the bill was being amended in the Senate, they don’t.
    But it didn’t matter as long as the Medicaid expansion was mandatory, which it was always supposed to be. But then the Supreme Court ruled last June that the expansion wasn’t required — states could choose whether or not to expand Medicaid eligibility to 138 percent of the poverty line. That’s an outcome no one saw coming, not even the people who wrote the law.
    By making the Medicaid expansion optional, the Court exposed this obscure mistake that had been buried in 906 pages of legislation. And it created a huge loophole: In states that aren’t expanding Medicaid, those “in-betweeners” — residents who make between 100 and 138 percent of the poverty line — will now qualify for tax subsidies to buy private insurance instead.
    “It was unintentional,” said one person who was involved in drafting the bill in the Senate. Like other sources interviewed for this story, this person spoke on condition of anonymity in order to speak candidly about the error and private deliberations around the ACA. “This strange confluence of events got us here. Nobody thought the Supreme Court would rule as it did,” the source said. “If the Medicaid expansion had occurred as we wrote it, then this wouldn’t have mattered. The number of turns in the plot was hard to anticipate.”

    That little quirk in the law will have a major impact. Nationwide, more than six million uninsured people fall in the critical 100-138 percent income range, between $11,490 and $15,856 for an individual. Right now, 13 states have said they won’t expand Medicaid, including large states like Texas and Pennsylvania. More than 2 million residents in those states are ‘in-betweeners’ and will be affected by the ACA error. Several other big states — including Florida*, New Jersey and Virginia — are still on the fence. If those places opt against expanding Medicaid, the number of those impacted could grow by another several hundred thousand.
    The bottom line is this: Thanks to an oversight four years ago on Capitol Hill, every one of those 2 million-plus people will be able to use federal tax subsidies next year to buy private health insurance.
    How the Mistake Happened

    Back in 2009, early versions of the Senate’s health reform bill included what was known as a Bridge Policy: people between 100 percent and 138 percent of the federal poverty level could choose whether they wanted to enroll in Medicaid or go through the marketplaces and purchase private insurance with a federal tax subsidy. That’s why the Medicaid threshold was capped at 138 percent, and the tax subsidy threshold initially started at 100 percent. (A sidenote: The ACA officially sets Medicaid eligibility at 133 percent of the federal poverty level. But the statute also allows for wiggle room of 5 percent, up to 138 percent, and that is the threshold that will be used for Medicaid enrollment in 2014.)
    Sources said the policy was offered as an olive branch to Republicans, who were wary of the government-run Medicaid program growing too large. The GOP preferred funneling more people to private insurance. An early iteration of the Bridge Policy was present in policy options submitted jointly by Sen. Max Baucus and Sen. Chuck Grassley to the Senate Finance Committee in May 2009. The policy in its final form (with the 100 and 138 percent thresholds) was part of the bill approved by the committee on Oct. 13, 2009.
    But it was also more expensive for the federal government. Medicaid, which is funded jointly by the states, costs Uncle Sam less than the tax subsidies, which are fully funded by the feds. So it would be cheaper to just enroll everyone below 138 percent of the federal poverty level in Medicaid, rather than give them a choice. And that’s why the Bridge Policy was ultimately discarded: The authors wanted to keep the ACA’s price tag down.
    When the Congressional Budget Office (CBO) came back with estimates of the bill’s costs, Senate staff decided the Bridge Policy was too costly to keep in the bill. No one can say for certain what the exact cost would have been, and the CBO analysis of the Bridge Policy was never released publicly. One source recalled that the Bridge Policy would have cost the federal government an additional $50 billion over 10 years. Another said that number was “too high,” but acknowledged that the costs were in the billions.
    So the Bridge Policy was eliminated when the Finance Committee bill merged with the health reform bill from the Health, Labor, Education and Pensions committee, one source said. That merged bill was sent to the Senate floor. Instead, the Medicaid expansion was supposed to cover everyone below 138 percent of the federal poverty level, while the tax subsides were intended to cover everyone above that. A manager’s amendment reworked much of the ACA’s language, incorporating changes to nearly every section of the bill from the floor debate and accompanying backroom negotiations. That’s the bill that was passed by the Senate on Dec. 24, 2009.

    But the tax subsidy threshold was never revised from 100 to 138 percent after the Bridge Policy had been removed, as it logically should have been. That was an unintentional oversight, said sources who spoke with Governing. How did they miss it while the bill was being rewritten? It appears to be as simple as this: The Bridge Policy and the tax subsidy section of the Senate Finance bill are separated by more than 100 pages. When one section was changed, nobody remembered to check the other.
    “I don’t want to imply that people were being sloppy. But when you take out the Bridge Policy, you’ve got to check in 20 different places to make sure everything matches,” one Senate staffer said. “This stuff was happening so quickly, and, at the end, it was quite messy.”
    The messiness of the ACA’s final days in Congress are well known. It was complicated after Democrats lost a seat in the Senate in January 2010 when Republican Scott Brown was elected in the Massachusetts special election to fill Ted Kennedy’s seat. Brown’s commitment to filibuster a conference bill, which would have reconciled differences between the Senate and House bills, meant that Democrats in the Senate couldn’t pass revised legislation as they traditionally would.
    Instead, the Senate bill was passed as-is by the House on Feb. 25, 2010. That legislation was signed by the president on March 23, 2010, with the mistake still intact. The House then passed a separate bill that amended some of the ACA’s language, but didn’t address the discrepancy between the Medicaid and tax subsidy thresholds. It’s possible they couldn’t be changed because of procedural rules, one source said. Regardless, the Senate passed the latter bill on March 25, 2010, and Obama signed it five days later.
    Even then, the error shouldn’t have mattered. As long as the Medicaid expansion was mandatory, the in-betweeners would simply be enrolled into Medicaid. But the Supreme Court’s decision last June changed that.
    “A Happy Coincidence”

    The irony here is that the mistake actually edges the ACA a little closer to its initial goal of universal health coverage — as one Senate staffer called it, it’s “a happy coincidence.” But no one could have predicted that outcome — not the authors, not the bill’s opponents, not independent legal analysts. (As one source explained, if the goal had been to create a fallback Plan B in case the Medicaid expansion was completely tossed by the Court, the bill’s authors would have set the tax subsidy threshold at 0 percent of the federal poverty level rather than 100 percent, so that everybody would be covered.)
    The statutory error, paired with the Supreme Court decision that made it matter, will also force the feds to spend their ACA dollars a little differently. A CBO analysis after the Supreme Court decision estimated that the federal government would spend an additional $210 billion on tax subsidies by 2022, although those costs were offset by $289 billion in savings on Medicaid.
    But the law’s authors chose to focus on the upside. Depending on how many states don’t expand Medicaid, as many as 3 million Americans will still get health coverage thanks to what seems to have been an honest mistake.
    “It didn’t really matter until June,” said one Senate staffer. “Then we all said, ‘Wait a second. What about that leftover thing from the Bridge Policy?’ So I guess you could say it was fortuitous or lucky.”

    *Since the initial publication of this post, Florida Gov. Rick Scott has endorsed the Medicaid expansion in his state.


    1. LillithMc

      Another macho attempt to rewrite legislation from the bench by the gang of 5 who have done more damage to the US than any other branch of government in the past ten years. By changing medicaid requirements they effectively gutted the bill.

    2. Lambert Strether Post author

      As I keep saying: The coverage you get from ObamaCare is random, unfair by definition. What about the other millions who aren’t covered?

      Worse, this all comes down to the system architecture: ObamaCare’s flaws derive fundamentally from throwing people into buckets of coverage with complex eligibility formulas: People always fall between buckets, or into the wrong bucket, or no bucket. (Here one contrasts the simplicity of single payer Medicare for All.) And what this shows is that these clowns can’t even get their own buckets straight!

      * * *

      The attempt by smug Democratic apologists to spin this humongous, grotesque drafting error* as somehow a positive is just infuriating.

      “The legislation is complicated. [sigh. shrug.]”

      Yeah, yeah. Do the jobs you’re paid to do and lucky to have!

      Honestly, is there anything the Democrats do that isn’t fucked-up and half-assed and full of blame-shifting and excuses?**

      NOTE * Never mind the strategic error of assuming the party that impeached Clinton over a ******* would co-operate in anything.

      NOTE ** I mean, aside from blowing faraway brown people to pink mist, sucking up to the banks, and Hoovering up every intimate communication you’ve ever had with anyone via phone or email.

  14. Alexa

    I echo Ms G’s recommendation that everyone read Lambert’s many excellent posts (regarding the PPACA) at Corrente.

    I believe that Mr. Dylan Scott is incredibly naive–if he actually believes what he wrote. (And I’m not convinced that he does.)

    Maybe the ACA will not be a fiasco for everyone, but for the lowest income Americans that it was obstensibly intended to help, it is clear that it will fall very short.

    1. Alexa

      Oh, and by the way, I don’t believe for a New York minute that the ACA would have been different (or better) if another candidate had won the election.

      Let’s not forget, John Kerry, the Dem Party nominee in 2004, also ran on a health insurance plank that “the American People will be able to pick their health care plans from a menu, much like their lawmakers do” (i.e., Health Exchanges).

      I am convinced that all corporatist Dems wanted the ACA.

      And as long as the ACA helps the folks that it was intended to (small businss owners/entreprenuers), and manages to relieve state and federal governments from bearing an increasing financial burden from health care costs (which the “mandate” does), I honestly can’t imagine that the ACA will be repealed.

      1. Lambert Strether Post author

        The difference between Obama and Clinton on health care in 2008 was marginal but not insignificant.

        1. Clinton wanted the mandate (and she was even honest about IRS enforcement). Obama did not. See here for Krugman excoriating Obama for his intellectual dishonesty on this point in 2008.

        2. Clinton accepted the principle of universal coverage. Obama, since he did not accept the mandate, rejected that principle.

        The net result is that Clinton was pushing the same conventional wisdom Obama was, but was actually concerned that — in its own terms — the plan would work, and she was open about what the plan would entail.

        The big difference is that by accepting the mandate and the principal of universal coverage, Clinton would have allowed single payer advocates to start (as it were) from the 30-yard line, because they alone can deliver on that principal (as we now see). Obama, by contrast simply threw them off the field.

        1. Alexa

          “. . . the Clinton plan is based on ‘choice’ and ‘competition,'” according to Clinton’s Senate legislative director, Laurie Rubiner.

          This quote is from the MSNBC September 2007 “First Read” piece entitled, “Hillary’s Health Plan.”

          Here’s the link (if it works):


          A couple more similar quotes:

          The Boston Globe has some of the GOP criticism. “Key elements of Hillary Clinton’s healthcare proposal are strikingly similar to the tenets of the health overhaul that Mitt Romney signed into law in Massachusetts last year.

          The Politico has the Clinton campaign’s response: “‘It’s sort of funny to me that [Romney] would cast it as a big government solution, when it’s essentially what he enacted in Massachusetts,’

          BTW, I was affiliated with a coalition that was also opposed to a mandate. (But I do realize that most establishment organizations supported one.)

          So although we agree on most issues pertaining to the PPACA, guess we’ll have to “agree to disagree” on this one.


          Also, there’s my concern of a “slippery slope,” as several of my posts at Corrente reflect, since there is talk of “mandated” long-term care, “mandated” unemployment insurance, and Tom Harkin’s possibly “mandated” USA Retirement Funds–reflect.

          Harkin claims that his fund will be an “automatic enrollment, opt-out” plan–but we’ll see.

          (I’m very pushed, so must apologize in advance for typos, etc.)

          1. Lambert Strether Post author

            You reinforce what I wrote; as I said: “Clinton was pushing the same conventional wisdom Obama was.” My argument is not that Clinton supported single payer, but that single payer advocates would have had better field position in a Clinton administration.

  15. clarence swinney

    Debunk the Myths in Investing (amazon) has some great suggestions:

    Effective health care delivery

    ObamaCare will have an impact on
    businesses. Large businesses will gain an edge over small businesses. Small
    businesses will suffer with several side effects:

    They will work around from the requirements of
    forced health care insurance by limiting the number of hours of an employee and
    the number of employees.

    Most of the new ventures are seeded from money
    from their home equity loans. With falling home prices, they will have less new
    businesses. The banks already have more restrictions in loaning money since

    Most proposals on health care
    delivery do not care about how to cut down costs, and how to make it fair and
    practical. We need to know how to pay for it first, how much, and the
    consequences to businesses and employment. My proposal and comments:

    1. Basic
    treatments for all.

    Better coverage is paid by an individual. We should
    encourage folks to work hard and there is no more free lunch. It is abnormal
    for the poor to have free health care while the middle class do not enjoy the
    same. The poor in Mass. receive free health care. I hesitate to go as I have to
    pay after the insurance.

    2. Fair
    regulation for nursing home.

    Those with low incomes and/or those without a house
    most likely can receive free nursing home care, free drugs and free doctor
    visits in most states such as Mass. Those in borderline qualify for the free
    nursing home care by giving their houses to their children, hiding their
    incomes and/or just quit working. They are lazy and not stupid.

    The government should spend an agreed percentage of the GDP on public
    health care. We can use the average percent from developed countries or let the
    voters to decide. We cannot ignore other spending such as education or let the
    budget unbalanced irresponsibly.

    When we over spend on any entitlement, there needs to be a corresponding hike
    in taxes. Though with high taxes, it
    reduces the United States’ global competitiveness and leads to further

    3. Prevention:
    Voluntary and non-voluntary (via taxes) on smoking, fast food, soda, etc.

    It is fair for the citizens to take care of their own health. You can
    select to live recklessly in unhealthy life style, but the rest of us should
    not be burdened with your bad habit.

    When we ban smoking totally, many hospitals ought to free up many resources. In
    addition, the second-hand smoke kills too. Why should we die for your bad

    4. Limit
    lawsuit award on malpractice.

    Our health care cost is being jacked up partly due to the legal expenses.

    Most do not realize these lawsuit awards will pass back to us. It is also the
    reason why the doctor would hesitate to care for us when we fall and lie on the
    street or why our clinical charges are so high?

    5. State-of-the-art
    treatments are less effective than prevention such as a low-dosage aspirin for
    all over 50 years of age and the routine shots for babies / children.

    6. Outsourcing
    the expensive treatments to foreign countries and drug development / clinical

    costs are outrageously high. Try some Caribbean countries, Thailand and
    Shanghai. The money we save pays for a free vacation, not mentioning the free
    massage every day for the entire trip. Many Caribbean countries offer same
    dentistry services at half the cost here.

    This is a temporary solution until we solve our cost problem at home.

    7. Cut
    down the expensive drug marketing (such as giving money / goodies to doctors).

    Personally I know doctors receiving free golf trips to the most expensive golf
    courses for the entire family. They also got unlimited lobsters in medical
    conventions in Boston. Should doctors receive the ‘lecture fees’ giving phony
    lectures or sales pitches in return of recommending the drugs or prescribing to
    their patients?

    Guess who ends up paying for all these goodies eventually?

    8. Stop
    the illegal aliens and foreigners from using our medical systems free.

    Their employers or the patients should pay for their expenses. It is nice
    to help the rest of the world, but we do not have money to do so now.

    Emergency room is the most expensive delivery method and its usage has been

    9. Importing
    foreign doctors and nurses is the worst we can do to a poor country.

    These foreigners are seeking a better economic life for themselves, but
    forget their original purpose of seeking these noble professions.

    10. Before
    we send soldiers abroad or explore space (both have some merits but the average
    citizen does not benefit from these ventures), should we solve our home
    problems such as health care first? Get our priority straight.

    11. The
    average last two years of one’s life would be the most expensive health care
    cost. Many do not want to live through pains and sufferings. Should we let them
    pass away in peace if they want to?

    12. Stem
    cell research has proven to be promising.

    We should not let our politicians dictate the policy
    for religious reasons. The desperate will go to foreign countries to receive
    the riskiest treatments anyway. Why let them know their risk and do the
    treatments here in a better environment?

    13. Stop
    all the insurance and Medicare frauds. If you spend $10,000 on inspectors and
    get back $1 million, it is a great investment.

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