ObamaCare’s Relentless Creation of Second-Class Citizens (5)

By lambert strether of Corrente.

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

In this series, we’ve been looking at how ObamaCare, through its inherent system architecture, relentlessly creates first- and second-class citizens; how it treats people who should be treated equally unequally, for whimsical or arbitrary reasons. It’s all in the luck of the draw! If you live in the right place or have the right demographic, you go to Happyville. If you don’t, you go to Pain City.

We’ve looked at the whimsical differences between the citizens of Libby, MT, and all other citizens; the banked and the unbanked; those herded into Medicaid and those who are not; the arbitrary distinctions between creatures of the Beltway and all others, between the covered and the not covered, and between those who will be marketed to, and those who will not; the sheer bloody randomness of relying on credit reporting agency data for income validation; and discrimination based on jurisdiction and geography. In this installment, I’d like to look once more at geographical discrimination, give an update on the creatures of the Beltway, and look at “churn.”

First, on geographical discrimination, this from the Portland Press Herald:

An Aroostook County resident who buys a health care plan on the new federal insurance exchange could pay $1,000 more per year in premiums than a Portland resident for exactly the same coverage, according to information released Wednesday by the Maine Bureau of Insurance.

The insurance industry lobbied for the changes, arguing that it costs more to deliver health care in rural areas. The legislation made it easier to charge different rates based on which county a buyer lives in starting in 2011.

$1000 is a lot of money! How can this differential possibly be justified in a program that’s supposedly there to aid citizens? It costs the Post Office more to move the mail from Aroostook County, but a first class stamp costs the same nationwide. We don’t change Social Security benefits by where people live. So why health care?

Answer: Because Obama and the Democrats had one key goal in designing ObamaCare: To preserve the health insurance industry. (As we all know, Liz Fowler, a Wellstone VP on secondment to Max Baucus’s office as chief of staff, wrote the bill.) If that’s your goal, regional variation discrimination by geography makes perfect sense. However, if health care is a right — and, to be fair, Obama does occasionally makes a rhetorical gesture in this general direction — geographical discrimination makes no sense at all. Unless you want to hollow out rural Maine, of course. So, if you live in the County, board the train to Pain City. And if you live in Cape Elizabeth, you’re already in Happyville!

Next, on creatures of the Beltway. First, I should say that I really don’t want to trash Congressional staffers, especially since the worse we pay them, the more likely it is that only rentier spawn will work on the Hill. I also know that Congressional staffers are not richly paid, and that free distribution of frozen Taco Bell food-like product is an event for them. That said, special treatment for creatures of the Beltway is exactly what’s going on, and Obama’s personally responsible it. Here’s the original problem statement from NC:


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.

[T]his “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.

Which — a call so obvious I can’t in good conscience take any credit for making it — is exactly what happened. Politico:

Lawmakers and staff can breathe easy — their health care tab is not going to soar next year.

The Office of Personnel Management, under heavy pressure from Capitol Hill, will issue a ruling that says the government can continue to make a contribution to the health care premiums of members of Congress and their aides, according to several Hill sources.

Just Wednesday, POLITICO reported that President Barack Obama told Democratic senators that he was personally involved in finding a solution.

Obama’s involvement in solving this impasse was unusual, to say the least.*

And let’s be clear about the problem that Obama personally solved. Forbes:

Because most Congressional staffers are poorly paid, but are paid enough to not have eligibility for the Obamacare subsidies that low-income Americans will receive, losing their current health insurance subsidies would be a big financial blow. Many members fear that their staffers would leave for better-paying jobs in response.

As has been repeatedly pointed out, there are millions of the working poor who are in an identical situation: “[P]oorly paid, but are paid enough to not have eligibility for the ObamaCare subsidies.” So, why don’t Congressional staffers just pay the penalty in the first year, and hope things will get more sane, like the rest of us poor schlubs? Well, basically, because they’re first-class citizens, on whose behalf Obama will bestir himself to get personally involved.** And first-class citizens go to Happyville, while the rest of us go to Pain City.

Finally, let’s look at “churn.”

Under the law, if a person’s annual income is below 138% of the federal poverty level — or about $15,850 — he or she qualifies for coverage under the Medicaid expansion.

This is not correct. You do not “qualify” for Medicaid in the sense that you have the choice of refusing it. You are forced into Medicaid, on the basis of your income.

If a person’s income is between 138% and 400% of the federal poverty level, he or she qualifies for federal tax subsidies to purchase private coverage through the state insurance exchanges.

However, normal life events — such as getting married or divorced, having children or taking a second job — can alter an individual’s income and push him or her back and forth between the two coverage levels, according to experts.

According to a 2011 study published in the journal Health Affairs, income fluctuations under the new law next year could produce eligibility shifts between Medicaid and subsidized coverage through the exchanges for as many as 28 million people.

Researchers found that those most at risk for fluctuating coverage are seasonal and hourly workers, as well as young adults who are not covered by their jobs or their parents’ health plans.

Health care officials who work with large Medi-Cal populations say fluctuations in eligibility cause the quality of care to decline and the cost of care to increase from added administrative expenses. Medi-Cal is California’s Medicaid program.

(To this I would add that if you’re over 55 and forced into Medicaid, your expenses will be clawed back from your estate.)

So, if you’re a seasonal or hourly (read: poorly paid) worker, or young, you’re faced with the stress of integrating into a new health care network whenever a “major life event” happens. Pain City, over and over again! So the Bible says, and it still is new…

What frosts me is that none of this suffering is needed. It’s all an inevitble consequence of ObamaCare’s system architecture. ObamaCare throws Americans into different buckets using a complex and confusing system of eligibility determination, and people inevitably get thrown in the wrong buckets, or land between buckets, or there aren’t even the right buckets for them. Adding to the mix is that buckets differ by state, both legally and in terms of insurance markets, and so what should be a simple, national system of Medicare for All instead creates second-class citizens all over the place, both within and between states.

Obama chose to go that route. Under a single payer system, where health care is a right, the eligibility paperwork is very simple. There is one form, and it’s already been filled out: Your birth certificate. And that’s how it should be.

NOTE * And since when does a President get personally involved in minor personnel matters? It’s bizarre, almost as bizarre as forcing down an airplane used by another head of state. Who does Obama think he is? The Decider?

NOTE ** Why not just go for outright feudalism, instead of mucking about with penny ante patronage deals like this? Cannot Obama have the courage of his convictions, if any?

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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. Ms G

    Great post – I always look forward to the next installment of this series!

    One minor “fix”:

    “$1000 is a lot of money! How can this differential possibly be justified in a program that’s supposedly there to aid [the[ citizens [who couldn’t afford insurance in the first place because It Was Too Expensive, or It Was Unaffordable?[!]”

    ObamaCare is like the Ogre who dresses up like a Good Fairy and turns back into an Ogre when you open the door — then it devours you alive.

    1. ima sleeper

      All true enough, but apart from academic satisfaction what exactly is the point of all this punctilious analysis? Isn’t it high time you guys focused on what can be done to right the ship?

      Who was the Wobbly who said, ‘don’t analyze, organize?’

      1. Ms G

        There is no “you guys” and “us guys” if you are reading and posting here. So … jump right into the fray and feel free to start “doing” in any way you see appropriate! Cheers!

  2. petridish

    “Cannot Obama have the courage of his convictions, if any?”

    As we used to say in college, “Surely you jest!”

    Obama has many qualities. “Courage of his convictions” is not one.

  3. Ms G

    “Why not just go for outright feudalism, instead of mucking about with penny ante patronage deals like this? Cannot Obama have the courage of his convictions, if any?”

    So Obama is not a Kenyan Socialist after all. He is a patroon. He runs a Clientage system in the manner of the Idi Amins and Mugabes or other IMF-financed third-tier “rulers” of this world.

    Note that Obama’s unusual intervention on behalf of the clientele in Congress, is of a piece with the massive chunk of ObamaCare cash (our taxes) that is being disbursed in the form of clientage payments (or “walking around money,” as you have put it elsewhere) towards the “creative classes” and navigator-community groups that provide all the irrelevant (unrelated to the delivery of health care) “services” created by the Rube Goldbergesque structure of this nasty system (PPACA).

    1. LizinOregon

      It’s my understanding that Members and congressional staff are required to purchase their insurance on their state exchange instead of through the federal health insurance program. The law failed to include language that allowed for them to continue to receive their current employer subsidy for their insurance – about 2/3 of the cost – and this is what the regulation would allow. They will still have to purchase insurance on the exchange in their state, but would get the same employer subsidy that other federal employees get. Granted, the regulation has not been published yet, but I would expect that it would be worded to try to give them the same subsidy other federal employees get. They could cap it at the max paid for the most expensive fed plan on the OPM “exchange”. Since it also covers Members, it will be interesting to see how it plays out.

      It is also beyond unusual for the President to be openly involved in regulation formulation.

  4. Ms G

    Does anybody know if the Creatures of Congress will still have to purchase defective and overpriced ObamaCare Insurance Products? And if so, whether Obama is ordering OPM to write the new regulation so that the Creatures at least get their subsidies applied to the Platinum plan (as opposed to the Loser (Silver), Super Loser (Bronze)?

    (I’m assuming that the Congressional Creatures, though not richly paid,(*) are not quite eligible for the You Are Not a Human Being (Medicaid) plans?)

    (*) which is debatable, when one asks “compared to what” — but that is another story. Plus they have jobs — and full-time, too!

    1. Code Name D

      I doubt it. After all, they have the money to buy into premium plans, which will probably offer a far better deal.

      But the thrust of the observation here is not about the congress critters them selves, but for their staffers, which are already under-paid as it is. (Most staffers are “interns” meaning they work for almost nothing – except for the “learning experience.”) I am sure they are concerned how it might look when they have platinum policies while their staffers get investigated for not having coverage that they can’t afford – let alone use.

      House servants usually have nicer cloths and bath regularly any way.

      1. Ms G

        Yes, re your observation about how it will look when Congress’s elected poobahs get their platinum policies and their quasi-intern staff end up buying only what they can afford — perhaps Super Loser Bronze (which is unaffordable anyway once you add in deductibles, co-pays, not-covereds, etc.)

        The circumstances seem ripe for an awakening by the staffers who presumably had some type of idealism when they decided to pursue the jobs they have.

        I don’t understand how even the dimmest or most corrupt (e.g., the ones doing this as a stepping stone to the lucrative revolving door path into “consulting” or being a FedGov vendor) cannot be having mental explosions — here they are aiding and abetting elected officials to shove ObamaCare’s bone-crushing program onto “us” citizens, whilst demanding a personal exemption from the lot that they help to impose on their “clients.”

        Will the sparks begin to crackle when staffers understand the gory financial details of their Bronze or Silver Insurance Products — even with a subsidy?

        In any event, if even one of those staffers had any real integrity he/she would have come forward and refused to accept the special-subsidy program on the basis that it is profoundly undemocratic and a deep stain on all staffers.

        1. Code Name D

          1st. It’s Lambert’s observation; I just rephrased it a little. Due credit where credit is due.

          2nd. After further reflection, I am not sure we should be all that concerned with congressional staffers just yet. From what I have gathered, from 2nd hand reports and casual antidotes, the majorities of congressional staffers are young, less than 25 years, and tend to come from well off families them selves. So they are likely on mom and dad’s platinum plans already.

  5. don

    I spoke by phone with my daughter this morning and she informed me that the company she works for, a major supermarket, is pushing to increase very substantially the workers monthly contribution for health insurance, to $300/month for an individual and $500/month for a worker with children, all based, according to the company, on ObamaCare, which she suspects is just an excuse being used by the company (a subsidiary of Kroger) to squeeze more from workers paychecks.

    1. Ms G

      Thank you for this report from *our* world, where the realitites of ObamaCare slam hard into our daily lives (and paychecks or pocketbooks).

      You have to wonder at this point if another intended (though not trumpeted) goal of PPACA was precisely to give employers who still provide health insurance a cover/excuse to move their health insurance cost-shifting maneuvers (already in high gear as it is) into fifth gear.

      Before the kleptocratic attack on union wages and benefits got rolling (mid-70s) union wages and benefits were a benchmark (and thus greatly benefited) private sector wages and benefits. Similarly today, as the kleptocratic program is in mission-accomplished mode with unions smashed and union wages and benefits shredded — Rahm Emmanuel is shoving Chicago public employees into the Exchanges — the benchmark still holds, except for the qualitative difference: private benefits, for example, are increasingly cost-shifted onto employees, which is what is happening to unions in the private and public sector (for the very few unions that are still in operation).

      And so ObamaCare brings us another nasty Easter Egg: the shredding of employer-provided insurance via massive shifting of costs onto employees (for what are probably increasingly the equivalent of “skinny” — catastrophic (useless) — insurance plans.

      BHO’s cruel cunning never ceases to amaze.

      1. ima sleeper

        The bottom line is simple. Individuals can survive this hopelessly corrupt fascist corporatism only by dropping out and constructing jobless lives. It isn’t easy but it’s still possible, at least for those opting not to breed.

  6. Malmo

    To those out there who claim Obamacare was a positive, yet incomplete, step in the right direction, I say, to be kind, you’ve been duped.

    Incrementalism, Obamacare is not. It’s a bureaucratic nightmare of the highest magnitude.

    At a minimum, it’s single payer or nothing, if we want a truly just heathcare system. It’s much easier to iron out any wrinkles with that as a base. Absent it and watch the have nots get screwed six ways to Sunday, same as it was before the legislation.

  7. Ms G

    At this advanced stage of Kleptocratic control I’m inclined to believe that “incrementalism” was always a neo-liberal code word for “it ain’t happening – ever,” except we’ll keep the marks biting on the bait with soothing promises of “we’re doing the best we can and working hard at it; working for you; be patient.”

    I think the hour has drawn near where the only legitimate response to the emergency situation that is the 99.9%’s economy is an emergency response — something equivalent to the Emergency Lending Facilities that the Federal Reserve made available to the newly-formed “bank holding companies” (Goldman Sachs, et al) in about five seconds after the GFC exploded.

    Why the “five seconds” response for banks and the “incrementalism” for the rest of us? That is asymmetrical. It is not equal protection or treatment. It is profoundly undemocratic.

    1. Saty13

      Very well said!
      But it’s time to do something about it. If you’re not REGULARLY writing letters and signing petitions and posting demands on social media for Congressmen, the SEC, the Fed, and the White House and everyone else who determines your fate, then you’re not doing your civic duty.

      We need to get organized and put pressure on the plutocracy. Obama keeps telling us to. Almost no one hears it in his speeched, but he says it repeatedly: If you want change, YOU have to demand it. He doesn’t have the power to do it within the system we have.

      Just casting your vote — as critically important as that is — is still not nearly enough.

      1. Ms G

        Uh … have you ever tried calling *your* senator to register support or opposition for pending legislation or to demand action in something not yet in legislation? I have. It is like calling a calling center that doesn’t exist anymore.

        And uh … how many petitions have you signed recently that actually led Obama or his Congress to do what you wanted them to?

        I agree action is required. I think we differ on the means.

  8. Jason Boxman

    Well that’s depressing. I’m embarrassed to admit I buckled under pressure to support the bill because it’s supposed to help poorer Americans. Just makes things worse.

    1. Lambert Strether Post author

      ObamaCare will surely help some individuals; a program so big can hardly help doing so. And no doubt ObamaCare’s (mostly taxpayer-funded) PR campaign will trumpet those success stories.

      All I want is equal treatment for all citizens so that everyone gets the same help that the success stories may. This ObamaCare cannot achieve, and by construction.

  9. Jim Haygood

    ‘There is one form, and it’s already been filled out: Your birth certificate.’

    Well, that’s true for most of us. Obama’s birth certificate — the one posted on the White House website — had close to ten layers in Adobe Illustrator, with obvious modifications on several of them.

    No, I’m not a birther. Probably he WAS born in Hawaii, and the crude alterations were to cover up something else deemed embarrassing — the real father’s name; the years-late filing of the certificate; that Barry was born before 21 Aug 1959 (Hawaii statehood); whatever.

    Point being that Obama is as phony as a three-dollar bill. He richly deserves the fate of having PPACA popularly called Obamacare, since it likewise is a pretty facade backed by nothing but damaged structure and missing parts. Let it bleed …

  10. Saty13

    I have no problem with geographical distinctions in pricing because there is a very real and high economic cost to deliver services to rural areas. Doctors, who are obviously among the most highly educated in our society, don’t like to live in remote areas where most people have only a high school education and are culturally and politically backward.

    Subsidizing people’s geographic isolation is not beneficial in the long run — culturally or economically. To be even more blunt I’m a little bit tired of subsidizing rurals who, based on their typical political beliefs, are too dumb to have figured out that the Right Wing corporatocracy is determined to turn them into peasants and is well on the way to succeeding.

    If Obamacare provides an incentive for people to concentrate around urban areas, it will be good for them and for us.

    1. Lambert Strether Post author

      I suppose if you could do that by denying them oxygen, you would? How sociopathic. Perhps you should go to work for the adminstration.

      Agricultural subsidies? Perhaps. But health care?

      1. AbyNormal

        thanks Lambert for the backslap…couldn’t find my breathe

        A man is responsible for his ignorance.

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