Opposition to ObamaCare Considered Rational on Grounds of Equity

From his latest presser, Obama’s partisan perspective on ObamaCare:

[OBAMA:] Now, I think the really interesting question is why it is that my friends in the other party have made the idea of preventing these people from getting health care their holy grail, their number-one priority.

However, from the public purpose perspective, the really interesting question is why our “friends” in both parties refuse to put truly universal coverage — for example, single payer Medicare for All — on the table at all. Remember, ObamaCare is, pathetically, projected to enroll only 7 million people in its first year, and when fully implemented will leave about as many uninsured as newly insured — 25 or 30 million, but with “these people,” who’s counting?

Be that as it may, we’re stuck with ObamaCare for now. And no matter what Obama says, the real problems with ObamaCare are not “glitches” and can’t be solved with “adjustments” or “administrative changes”‘; they are fundamental to its system architecture, which demands that every American be thrown into one eligibility bucket or another, with the number of possible buckets being 1 (Federal) x 50 (states) x 9 (the number of income levels) = 450. At least I think so.* Maybe somebody smarter than me wants to calculate the combinatorial explosion, taking the differences between the actual plans offered in each jurisdiction into account. Anyhow, as I’ve been relentlessly documenting, ObamaCare’s complex, confusing, and Rube Goldberg-esque system of eligibility determination mean that people inevitably get thrown into the wrong buckets, or there aren’t even the right buckets for them. Worse, people are thrown into buckets for whimsical and arbitrary reasons, leading to a fundamental lack of equity, of common fairness, for the entire program. Today I’d like to ObamaCare’s fundamental lack of equitable treatment for all citizens by using Kaiser’s Subsidy Calculator** for people at “the margins”: Those at the top, too well-off to participate in the Exchanges, and those at the bottom, too poor to do so. For continuity with this (conservative) example, the test case will be a family of two 56-year old non-smokers, with two children under 20.*** (Hat tip Beowulf — yes, that Beowulf — for the example, and for extending it to the poor.)

First, let’s define the margins:

If your income is lower than 400% poverty level [top, maximum], you will receive assistance paying for your health insurance and if you earn less than 138% poverty level [bottom, minimum], you will be eligible for Medicaid – unless you are in one of those states that made the ridiculous decision not to expand Medicaid coverage for their poorest citizens.

(Matters are actually more complicated; the maximum is 400% of poverty level or 9.5% of income, whichever is least.) Taking our income figures from the 2013 Poverty Guidelines, let’s plug the figures at the top margin (400%) household into the calculator:


Now, since we’re at the margin — 400% of the poverty level exactly — let’s add a dollar and see what happens:


Before: $18,637 unsubsidized – $8,160 subsidy nets to $10,477. After: $18,637 – 0 = $18,637. That extra dollar of household income at the margin cost you $8,160 dollars worth of (actuarially determined) health care. I ask you: How can effect so grossly disproportionate be fair? Is there any way for a health care program to justify this? And that’s before we realize that a relatively well-off household is going to be able to afford the professional services to manage their income so as to retain the subsidy. Of course, this obvious inequity is a consequence of Obama’s system architecture: Buckets have edges, and people fall in a bucket, or out of it.****

And now, let’s plug the figures at the bottom margin (138%) household into the calculator:


And now one dollar less:


Before: $18,637 unsubsidized – $17,383 subsidy nets to $1,254. After: Medicaid.

Never mind that some states “expanded” Medicaid and others did not. Here is the central point of unfairness for me, and the Kaiser site describes it falsely. They write: “[Y]ou will be eligible for coverage.” In fact, you aren’t “eligible,” because you don’t have a choice. You’re forced into Medicaid. This is important if you’re over 55, because Medicaid expenses will be clawed back from your estate.***** ObamaCare, in other words, prevents you, by force majeure, from providing for your children if you’re poor and over 55. You don’t even have the option of taking on risk by buying a crappier policy. How can that be fair? 

The bottom line, again: ObamaCare, by its very system architecture, is riddled with these nutty distinctions, these whimsical and arbitrary inflection points, where a dollar this way or that way has massive and disproportionate effects that play out with people’s health (for pity’s sake). That’s why health care should be a guarantee — and although Obama occasionally nods to universality, he’s very careful not to deliver it — and a clean and fair system like single payer Medicare for All is the right way forward. 


* It’s true that only 17 states are building their own exchanges, but I think that different states can have different policies even if they are using the Federal exchange. All this when we have a proven single payer system in action already — Medicare — which LBJ rolled out to all over 65s in just one year, back in the day when Big Iron mainframes roamed the earth, and women wearing bunny ears was considered quite the thing. All in all, ObamaCare seems like a case of what Yves calls devolution. Infestation of the body politic with rent seekers will do that.

** Here’s Kaiser’s caveat on its calculator:

We assume an average premium for a single adult enrolled in the second-lowest cost Silver plan to be $4,827 (before subsidies). This estimate was derived by multiplying the CBO estimate for a family premium by 37% (the average ratio of single to family premiums in previous CBO estimates) and then adjusting for assumed inflation and differences over time in the aggregate reinsurance pool to arrive at a 2014 estimate. Premiums could vary from this amount due to assumptions insurers make in setting premiums or the degree of competition in the market, and will also differ based on regional variations in underlying health costs.

In addition, the entire notion of calculators is flawed: Exchange values, and hence the values the calculator spits out, represent actuarial values, not the dollar value of real services delivered, and as a study from Kaiser shows, actuarial values can differ wildly by insurer (i.e., can and therefore will be gamed). Of course, the details are obuscatory. From Kaiser:

[T]he levels of coverage in the ACA are not defined using specific deductibles, copays, and coinsurance. Rather, they are specified using the concept of an “actuarial value” (AV). … [A]ctuarial values are not an inherently intuitive idea for most people, so the Kaiser Family Foundation initiated a study to estimate the deductibles and coinsurance that would meet the thresholds defined in the ACA. Because there is inherent uncertainty in actuarial analysis – driven by different assumptions and data – the study commissioned estimates from three well-established actuarial and benefits consulting firms. … Apart from the specific details of any of the plan designs, one notable conclusion from the analysis is the substantial variation in the estimates … The analysis also points to the potential for substantial variation in plan designs meeting the actuarial value thresholds in the law, suggesting that the terms of coverage could vary significantly across insurers. 

In other words, when Obama said that buying insurance on the exchanges would be like buying “a flat screen TV,” he was at best ignorant, and at worse was flat-out lying.

*** The effects are smaller for smaller families, but the principle remains the same.

**** Some might make a similar argument against progressive systems of taxation. Since taxes don’t fund spending, the same government services can be delivered regardless of tax structure. However, one might, from the perspective of public purpose, support a steeply progressive tax system (the top rate under Eisenhower was 91%) to prevent the development of an aristocracy of inherited wealth (unfair) and/or to prevent the rich from buying the State (also unfair) with the loose cash they’d otherwise squander on yacht covers and expensive handbags. (It seems to me there’s a difference between passing on creature comforts to one’s heirs, if any, and (say) entailing an estate, let alone primogeniture. Perhaps that is a petty bourgeois perspective, or a perspective limited by the post-World War II fashion for homeownership. And a discussion for another day.)

***** To be fair — and I’m guessing here — if you’re poor and at the 138% margin, your income is more likely to fluctuate than if you were destitute, or (relatively) well-off, and so you’ll be falling into Medicaid and then escaping into the Exchanges again. 

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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. MIWill

    Total number of buckets should include state and federal prisons for those caught in the perjury trap.

  2. LAS

    Medicare for all may be a better solution. I would prefer it for myself at least. Medicare has been in existance for some time and the understanding of how it works better seen. However, and this you don’t say, Medicare is not complete either. It has gaps. Statistically significant dis-equities of outcome occur under Medicare too, caused by ability to afford/not afford Medicare supplement insurance. Economic studies in health affairs have shown that persons with supplemental insurance get more and better medical attention than persons without the supplemental insurance.

    Income inequality is hard-baked into this American society. It is valuable to understand its reification in the new Affordable Care Act, but that we find it does not invalidate the program.

  3. LAS

    I am glad to read examples of how the ACA is likely to impact people when it rolls out.

    Only I think you are leaving unsaid the fact that Medicare is also incomplete. There are gaps in its coverage. Economic studies in health affairs have shown that medical attention is significantly different (better) for Medicare recipients with private supplemental insurance than for persons with Medicare alone. The incremental benefit of moving from Affordable Care Act to Medicare for all may not be entirely all that you imply.

    Social inequity is hard-baked into American society.

  4. Jefemt

    The part I most adore is that the money goes to insurors,who have denied my lovely wife coverage, or reasonably priced coverage, for over 35 years. we now are forced gun to the temple to give them 20% of our annual gross. Super neat and we am enthused!! Not one penny directly to caregivers. what a concept! What a country of saavy bidness people! So efficient!I remember nearly barfing when I saw the former head of united health care retire with over a billion with a b in cash, stocks, hookers and cocaine. I swore that I would never, ever ever participate in supporting that parasitic, non-productive aspect of our society. Well, never say never… apologies for the poison so early in the day

    1. Yalt


      Waste and jobs are two sids of the same coin.

      Most of us, in one way or another, make our livelihood by assisting with the business of rent extraction. As long as that’s the case and as long as we’re all reliant on that livelihood for survival, any serious attempt to cut parasitic, non-productive waste is going to be difficult.

      We’ve seen how this works for decades in the defense industry. Now we’re adding risk-management-Keynesianism to the military kind.

      To behave otherwise would require talking about fundamental issues of property relations in this society and, as we already established last week, that issue is off the table.

      1. F. Beard

        Waste and jobs are two sids of the same coin. Yalt


        Restitution in the Bible is not giving the victim a government job; it is returning the stolen goods or equivalent + additional compensation for the trouble.

        The rich and/or the so-called creditworthy are allowed to steal by what is essentially a government-backed counterfeiting cartel, the banking system. The just solution is not jobs but a return of the stolen property and the abolition of the means of theft.

      2. hunkerdown

        “Waste and jobs are two sids of the same coin.”

        Perhaps we’d better start thinking of other systems of distribution then, since wage labor is failing many of us.

  5. Klassy!

    [OBAMA:] Now, I think the really interesting question is why it is that my friends in the other party have made the idea of preventing these people from getting health care their holy grail, their number-one priority.
    Now I think the really interesting question is why my the president conflates a mandate to purchase an overpriced product with “getting health care”.

    1. NotTimothyGeithner

      Obama is like most people. He doesn’t care beyond he has his and to hell with everyone else.

      Go back to his celebrated 2004 DNC speech. I thought it was trite and shallow, but what was the basic message? The basic message was problems are the result of whining and all our problems can be solved by ending the imaginary divides.

      In a generic sense, the differences between Canadians and Americans (Catholic/Protestant; Jew/Muslim; Orthodox/Thor Worshippers;) are meaningless, and people love to pretend they wouldn’t divide into chimps/orangutans/gorillas. It would be absurd to deny the message that Howard Dean and John Edwards both put out if you think at all. You might argue over there sincerity or solutions, but they pointed out that there were significant divides in American society. Edwards is obviously the Two Americas, and Dean is the return to a people powered organization from a leadership which was not answerable to its base. What does Obama say, “there is only the United States of America,” after his utterances of a repeating message of there are no divides. Most of the listeners didn’t care because its just rah rah for the masses, and there was boomlet coming through. Many people when were coming of age, and Obama was the first person they heard give a rah rah speech besides the imagery associated with Obama when they confronted with the option to vote who wasn’t part of the past or burnt out too soon like Dean. Obama’s basic message is to completely contradict the message of the Democratic VP candidate and the guy who would become the DNC chair.

      Lets move to his speech on race. Despite crippling poverty in the U.S. especially among African-Americans, Obama brought up improving one’s lot through the imagery of Michelle’s father and said he was an example of what people should be like. Not once does he mention that the job Michelle’s father had isn’t available anymore. It doesn’t affect Obama, so it doesn’t bother him.

      This is what Obama is, he’s a shallow American who is safe and very well off, and no one has brought him to task for one reason or another. Obama is a selfish man, but I think he would respond to a problem which affected him or could affect him. The legions of young African-American men who are killed/arrested every year in urban communities don’t bother Obama, but the death of a kid who sort of looks like Obama in a white and a wealthier neighborhood gets a response. I don’t doubt his sincerity on the matter of Travon Martin because Obama made it about Obama, not a child, his own kids, or Obama’s status as a parent, and Obama is the pinnacle of small mindedness and selfishness in this country.

        1. NotTimothyGeithner

          I should have been clearer, but I should have added was the phenomenon of people who haven’t been sick and are happy with their healthcare. Healthcare is overpriced at every point, but its not a direct problem for many people. Obama-Care has things which sound good, and for people who are not suffering, Obama-Care is great because they aren’t experiencing the problem and it sounds like the problem is solved.

          Obama is particularly loathsome and selfish, but his nature is still connected to this phenomenon of not grasping or caring about a problem until he is directly faced with it. Obama is like the legions of “I’ve got nothing to hide” totalitarians. Take any of the Republicans who found out they had a gay family member or some disease family and finally became crusaders for what was right. If Obama or one of these people had a problem, they would throw a fit. I read a letter to the editor about land use, and the author complained about development but proceeded it with the disclaimer that he isn’t some tree-hugger who cares about the environment. He wanted support to protect his trees. Obama is the same guy but more successful.

          Perhaps, its a bit much to say “most people,” but when you have so many people living pay check to pay check, its tough to get them to live beyond the immediate.

        2. Zadoofka Florida

          He could have showed EMPATHY by vacationing in hard hit by Hurricaine Sandy, Seaside Heights, NJ instead of snooty
          Maaaatha’s Vinyaaad. Could have put some $$ into the local economy there.

      1. Klassy!

        “The basic message was problems are the result of whining and all our problems can be solved by ending the imaginary divides.”
        And that he was sent here to bridge that divide. Like someone wrote one time, he is not the president of pundits.

      2. deconstructingpoliticalspin


        “Obama is like most people. He doesn’t care beyond he has his and to hell with everyone else.”

        You may have nailed it.

        Or as Chris Hedges might say about our “Establishment (Faux) Liberal Elite”:

        “I learned to dislike liberals when I lived in Roxbury, the inner-city in Boston, as a seminary student at Harvard Divinity School.

        I commuted into Cambridge to hear professors and students talk about empowering people they never met.

        It was the time of the leftist Sandinista government in Nicaragua. Spending two weeks picking coffee in that country and then coming back and talking about it for the rest of the semester was the best way to “credentialize” yourself as a revolutionary.

        But few of these “revolutionaries” found the time to spend 20 minutes on the Green Line to see where human beings in their own city were being warehoused little better than animals.

        They liked the poor, but they did not like the smell of the poor.

        It was a lesson I never forgot.”

        (Is there a way to include a “link” in a comment here, please? Thanks.)

  6. Jim Haygood

    ‘[A]ctuarial values are not an inherently intuitive idea for most people.’

    Understatement of the year?

    At a minimum, actuarial calculations involve net present value calculations. The math isn’t that complicated. But not too many people outside of finance have been introduced to it.

    Actuarial calculations for life insurance are pretty straightforward … IF you are dealing with the general population, whose average remaining life expectancy can be very accurately estimated for a large cohort. However, when ‘buckets’ start being introduced — smoking, obesity, medication use — suddenly the underlying assumptions are all-important, and the uncertainty range is much higher.

    In the case of Obamacare, the buckets represented by the first year’s ‘seven million served’ (as McDonald’s would put it), along with how they distribute themselves among the providers in the exchanges, is wildly uncertain. How insurers can even hit the side of a barn with their actuarial forecasts is a mystery. (That’s what discretionary premium hikes are for!)

    How much detail do state regulators receive in connection with those actuarial estimates? Presumably insurers and regulators enjoy the same cozy, nontransparent, co-opted biz-gov partnerships that characterize most existing insurance markets.

    I’d like to see a real-world example of the 60% actuarial value calculation for a bronze plan. But I’m not expecting to encounter it on any exchange sites. After all, little people shouldn’t trouble their woolly heads over complex matters that are best left to exports.

    1. Ms G

      “But I’m not expecting to encounter it on any exchange sites.”

      Not to mention that any specifics about how much these “products” will in fact cost (burden families) will not be particularly helpful to Obama’s “Enroll America” PR Campaign.

      It is only when the real price of admission (premiums) and price of (non)use (deductible, co-pays, not-covered-this-that, 30% or 40% not covered period, etc.) is revealed to the customers (marks), that the true face of ObamaCare will become apparent to the customers (marks).

      And *that* moment will not be pretty. (Personal bankruptcy attorneys across the country should be ramping up their Chapter 7 teams.)

  7. Old HIckory

    In addition to the operational complexity, the major failing of the ACA is that it does nothing to address the price-fixing and other rapacious practices throughout the health “care” industry. The only real beneficiaries of the program are the insurance companies and the top people at United Health Care, HCA, etc.
    Why most people can’t see that is beyond me.

    1. Yalt

      That’s a failing?

      The bill effectively consists of two parts:

      1. An extension of medicaid, in particular to provide coverage to single adults, and

      2. A grant of a massive public subsidy to the existing system of price-fixing and other rapacious pratices.

      It’s hard to quarrel with the former, though we could do a lot better, but the meat of the bill is #2 and to describe it as a “failing” is to misunderstand the purpose of the legislation.

      1. Ms G

        “2. A grant of a massive public subsidy to the existing system of price-fixing and other rapacious pratices … [T]he meat of the bill is #2 and to describe it as a “failing” is to misunderstand the purpose of the legislation.”

        Absolutely. You know that, Lambert knows that, and a few of us know that. ObamaCare is a system engineered to enable more streamlined and widespread looting by the Ins.Co’s and related industries (pharmas).

        In fairness, though, neither Obama’s press office, nor Sebelius’s press office, nor the anemic MSM PR stenography has particularly highlighted this central fact about the PPACA. And by design, because the whole thing is a vast con on the targeted consumers.

        So perhaps we can forgive those who are still experiencing the cognitive explosions that come with comparing facts about PPACA (as they dribble out) versus the false advertising that PPACA is about “affordable” anything.

        1. Yalt

          I think there’s more to it than that, other interests and viewpoints in play here.

          Number one, obviously, is the one we’re discussing. A parasitic industry has been invited to write its own meal ticket and has done so.

          A second point of view–for what it’s worth this is Obama’s, not that that matters since, like most presidents, his personal opinions are as relevant as those of a PR flak delivering a carefully prepared press release–is that there are a lot of jobs at stake here. All that wasteful health expenditure is, on the other side of the ledger, a lot of revenue for somebody, and some of that income is put toward wages and salaries.

          That’s capital’s hand every time, and no one seems willing to call it. From banks to defense to healthcare, jobs and thus livelihoods are tethered to the ability to loot. We’re a nation of middlemen. No, that’s not quite right…a nation of middlemen’s henchmen.

          Breaking that tether would involve fundamental changes in property relations. That’s beyond the pale, which means we can’t even talk about how any of this could be different. We can’t possibly feed and house people without passing the money through a gauntlet of rent-seeking middlemen. That would be socialism. Socialism is bad.

  8. charles sereno

    I can imagine the cloistered laughter of all the A-holes (who designed the Obamacare maze) looking down on Lambert trying to map it out when he’d be better served tending his garden. You A-holes!!!

  9. Francois T

    What this very good post totally neglect is…history.

    I’m talking about the history of any law that initiated big changes in the US. Look at minimum wage, Social Security, Medicare, Medicaid…name it!

    Each and everyone of these laws was woefully inadequate in its first approved iteration. Lawmakers were (or quickly became) keenly aware of these problems. Take Medicare for instance: If memory serves me correctly, it was tweaked and modified no less than 27 times in the first two years after it was signed into law. Oh! We’re not talking about changes like who shall sit here or there at the supper table, but steak and potatoes changes. Ditto for Social Security.

    What is very different now, and what most people fail to appreciate, if the fact that Republicans have decided that Obama would not have his victory, no matter what. Their strategy (if we can call that a “strategy”) is absolute scorched earth; the only reform is repeal.

    Well, this has profound consequences because it will be impossible to improve ACA until the Republicans either change their tune, or are so thoroughly crushed in 2014 or 2016 that they can’t block anything anymore.

    None of these 2 alternatives appear very likely now; the first, because the GOP electoral fate is in the hands of their primary voters, (a.k.a. the zealots) and redistricting plus the Supine Court have seen to it that the Republicans shall be able to dictate their agenda (say No to everything that is not what they want) no matter what, ergo, unless a massive sea change in the electoral habits of ordinary Americans take place, the situation will reek of toxic status quo.

    They say that elections have consequences. We’re all staring at a very big set of consequences right now; and it’ll get much uglier before it gets any better.

    1. pebird

      When it comes to violating the Constitution, the President has no problem issuing secret executive orders and adminstrative rulings. But ObamaCare can’t be tweaked due to Congressional politics. Well, how convenient.

      1. Francois T

        Show us how could Obuster could circumvent Congress on the ACA right now.

        Inquiring minds are eager to know.

        1. Lambert Strether Post author

          Well, the deadlines Obama blew off on the employer mandate and income validation are hard-coded in the statute. So Obama’s already circumventing Congress. It’s just a question of how and for whose benefit.

    2. Lambert Strether Post author

      Did you read the post? Here’s the history:

      Medicare — which LBJ rolled out to all over 65s in just one year, back in the day when Big Iron mainframes roamed the earth, and women wearing bunny ears was considered quite the thing.

      If you’ve got a simple and robust system architecture like Medicare, then it’s easy to roll it out fast. When you’ve got a complex Rube Goldberg device like ObamaCare, that becomes harder. I didn’t claim that Medicare was perfect, and of course there will be glitches in ObamaCare that will be fixed. But if you look at history, there are orders of magnitude more glitches than there should be, and they will be more serious.

      So, you’re straw manning.

      1. Francois T


        I read the post, but I wonder what you read in my comment. I never implied that you wrote Medicare is perfect yada yada. What I was trying to point out is the mere fact that this kind of orchestrated total obstruction to ANY change is unprecedented.

        Moreover, you made my point even more strongly than I could: Yes, Medicare was much simpler than the abomination that is the ACA. Yet, DESPITE Medicare comparative simplicity and elegance, it required major tweaks right after its roll out.

        Thus, it is imperative that the ACA be modified in depth; there is no doubt about that, the facts you presented illustrate that perfectly. Show me where I argued against that.

        1. Yves Smith

          My understanding of the subsequent changes for Medicare was that they weren’t “fixes” as much as tidying up imprecision or ambiguity in the drafting, and that that’s pretty routine for major legislation.

    3. Waking Up

      Francois T:

      As long as people analyze every issue as a Republican/Democratic party issue where the “nasty” Republicans are to blame for everything…if, we could just get rid of those “nasty” Republicans…then nothing WILL change. In case you haven’t noticed, the Democratic party, and specifically this President, have been complicit or outright advocated for many of the policies we see now. Whether it’s drone missiles killing innocent people, spying on our e-mails and phone calls, attacking our right to protest (learn about how Occupy was treated), Arne Duncan/Obama push for Charter/Private schools, lack of accountability for financial institutions, or the push for Obamacare which ALWAYS was a means for the private insurance/pharmaceutical companies to make even larger profits. The only difference at this point is the Republican party is blatant and “in your face” about their views while the Democrats get the same results in a “somewhat” more subtle manner. BOTH parties represent corporate interests. NEITHER party represents the people of the United States. Don’t expect real progress on any issue unless people recognize this and begin looking for true alternatives.

      1. Ms G

        And let’s not forget BHO’s other “signature” project: “The Grand Bargain.” whereby this current “Democratic” President is forcefully working to throw 99% of Americans into poverty, indignity, hunger, ill-health and third-world-style deaths.

        Just to round out an otherwise comprehensive list of “bad things” that are desired, owned and aggressively being executed by BHO himself. Obama may well be simply a “yes massah” lackey for the FIRE sector (that’s the charitable and unrealistic option), but there isn’t an odious action he has taken or word he has uttered that was caused by pressure from the republicans.

        1. deconstructingpoliticalspin

          Ms G,

          The “Grand Bargain” is a construct of the DLC/Third Way, not just this Administration.

          You might want to Google the following:

          DLC | Key Document | August 1, 2000

          The Hyde Park Declaration: A Statement of Principles and a Policy Agenda for the 21st Century


          The DLC was a Clinton organization. As a matter of fact, according to Wikipedia:

          “On February 7, 2011, Politico reported that the DLC would dissolve, and would do so as early as the following week.[4]

          On July 5 of that year, DLC founder Al From announced in a statement on the organization’s website that the historical records of the DLC have been purchased by the Clinton Foundation.[5]”


          But I agree–the “Grand Bargain” is an atrocious idea.

          And if progressives don’t stop it, the Democratic Party will probably lose the WH for many years to come.

          1. Ms G

            Tx for the backgrounders. I see Obama as organically linked to the DLC and Third Way so I do not make the distinction you suggest as I do not believe it is justified. All one “party” — and it includes the Hamilton Institute, of course (and Maestro Rubin).

        2. Doug Terpstra

          Obama never lets a crisis go to waste; he invariably turns every one into an unmitigated disaster. And the cult congregation dutifully says amen.

          Bravo to Lambert for so much heavy lifting on this monstrosity. The Obots couldn’t get traction on revising the single-payer shutout. Funny how the Stasi master and drone assassin is so selectively impotent.

      2. Francois T

        As a physician myself, I am acutely aware of the numerous shortcomings of the ACA. I followed this whole saga closely. The short of my opinion about Obama’s conduct of this whole affair: he sucked! Real bad! Letting CONgress and the special interests run the show just to get a bill wasn’t exactly what the dictionary state about the term “leadership”.

        That was then, this is now! We’ve got a law that changes a lot of things in the US health care non-system. Significant portions of this law MUST change in order to work half decently.

        I merely tried to point out that right now, August 2013, those who systematically obstruct the possibilities of change are the Republicans.

        But this is America 2013 and it shall be prohibited to point out the obvious if a political party is more responsible than the other.

        1. Ms G

          The main thing “wrong” with PPACA is that solidifies the position of insurance companies within a so-called health care system. All other issues flow from that simple fact. Removing insurance companies from the health care system is therefore Step 1. If you would like to call that a “tweak,” then so be it.

          Many doctors hate Medicare for All because they see it as a threat to their ability to earn “big” as doctors. Thus I applaud and support PNHP, who appear to agree that making a decent living but not buying luxury cars and multiple homes is just fine.

        2. Lambert Strether Post author

          No, it isn’t only the Republicans who obstruct things. Show me Democrats in Congress supporting single payer waivers in the states, for example, or rolling back the start date from the absurd 2017 to, say, 2014. Both legacy parties collaborate to take single payer Medicare for All off the table.

    4. nobody

      Leaving aside what a malevolent atrocity ObamaRomneyWellPointCare actually is, it seems to me that, given the general state of affairs WRT the financial crisis when Obama was inaugurated, making healthcare “reform” the main agenda of your first term is rather like attending to your urgent termite problem when the freaking house is on fire.

      Recall how we got here. Early in 2009, the banking industry was on the ropes. Both the stock and the credit default swaps markets said that many of the big players were at serious risk of failure. Commentators debated whether to nationalize Citibank, Bank of America, and other large, floundering institutions.

      The case for bold action was sound. The history of financial crises showed that the least costly approach is to resolve mortally wounded organizations, install new management, set strict guidelines, and separate out the bad loans and investments in order to restructure and sell them… Shuttering sick banks is hardly a radical idea; the FDIC does it on a routine basis. So the difference here was not in the nature of the exercise, but its operational complexity.

      This juncture was a crucial window of opportunity. The financial services industry had become systematically predatory. Its victims now extended well beyond precarious, clueless, and sometimes undisciplined consumers who took on too much debt via credit cards with gotcha features that successfully enticed into a treadmill of chronic debt, or now infamous subprime and option-ARM mortgages.

      Over twenty years of malfeasance, from the savings and loan crisis (where fraud was a leading cause of bank failures) to a catastrophic set of blow-ups in over the counter derivatives in 1994, which produced total losses of $1.5 trillion, the biggest wipeout since the 1929 crash, through a 1990s subprime meltdown, dot com chicanery, Enron and other accounting scandals, and now the global financial crisis, the industry each time had been able to beat neuter meaningful reform. But this time, the scale of the damage was so great that it extended beyond investors to hapless bystanders, ordinary citizens who were also paying via their taxes and job losses. And unlike the past, where news of financial blow-ups was largely confined to the business section, the public could not miss the scale of the damage and how it came about, and was outraged.

      The widespread, vocal opposition to the TARP was evidence that a once complacent populace had been roused. Reform, if proposed with energy and confidence, wasn’t a risk; not only was it badly needed, it was just what voters wanted.

      But incoming president Obama failed to act. Whether he failed to see the opportunity, didn’t understand it, or was simply not interested is moot. Rather than bring vested banking interests to heel, the Obama administration instead chose to reconstitute, as much as possible, the very same industry whose reckless pursuit of profit had thrown the world economy off the cliff. There would be no Nixon goes to China moment from the architects of the policies that created the crisis, namely Treasury Secretary Timothy Geithner, Federal Reserve Chairman Ben Bernanke, and Director of the National Economic Council Larry Summers.

      Defenders of the administration no doubt will content that the public was not ready for measures like the putting large banks like Citigroup into receivership. Even if that were true (and the current widespread outrage against banks says otherwise), that view assumes that the executive branch is a mere spectator, when it has the most powerful bully pulpit in the nation. Other leaders have taken unpopular moves and still maintained public support.

      Obama’s repudiation of his campaign promise of change, by turning his back on meaningful reform of the financial services industry, in turn locked his Administration into a course of action. The new administration would have no choice other that working fist in glove with the banksters, supporting and amplifying their own, well established, propaganda efforts.

      Thus Obama’s incentives are to come up with ‘solutions’ that paper over problems, avoid meaningful conflict with the industry, minimize complaints, and restore the old practice of using leverage and investment gains to cover up stagnation in worker incomes. Potemkin reforms dovetail with the financial service industry’s goal of forestalling any measures that would interfere with its looting. So the only problem with this picture was how to fool the now-impoverished public into thinking a program of Mussolini-style corporatism represented progress.

      The incoming administration could have done with the Too Big To Fails what was recommended in the paragraphs above, along with creating a public work relief program like FDR’s CCC to address the employment crisis (which is continuing to destroy millions of lives and is killing lots of people), and then used the bully pulpit and all of the legislative and public opinion shaping tools and tricks that exist to pass Medicare for All.

  10. Ed Bradford

    With all due respect, if central planning for the economy always fails, why would central planning for health care succeed. The article above demonstrates the politics already in ObamaCare and doesn’t even discuss in detail that infamous panel that will set prices. If America doesn’t wake up very soon, we will have the worst healthcare system design in the world.

    1. diptherio

      Central planning for the economy always fails? Do you mean like the interstate highway system? Or maybe you consider the TVA an economic failure? What about those centrally planned hydro projects the Bureau of Reclamation runs? Trust me, the locals in Fort Peck are convinced of the economic benefits of central planning.

      You create a false dichotomy with your statement. The reality is that some centrally planned projects work and some don’t.

      Also, there is already an “infamous panel that sets prices,” maybe you missed it:


      1. Jim Hayward

        Interstate highway system — the subsidized roads that created sprawl and left the U.S. with weak rail infrastructure?

        TVA — the subsidized power that eradicated poverty in Appalachia (not!)?

        Fort Peck — the series of Missouri River dams that probably wouldn’t be built today if environmental impacts and cost-benefit ratios were considered?

        Reasonable people can disagree on these examples, but the only slam-dunk proofs they provide are that centrally-planned megaprojects invariably involve complex tradeoffs, which some stakeholders would flatly reject.

    2. petridish

      May I be the first of what I assume will be many to respond that we already DO have the worst “healthcare” system design in the world.

      1. Waking Up

        Exactly! It’s just decades of really good propaganda that led people to believe our health care system is even remotely good.

        Tommy Douglas introduced Canada into the first Single-Payer program with REAL Universal Health Care. In 2004, he was named the “Greatest Canadian”. There are many other health care systems around the world far superior to that in the United States. Obamacare doesn’t even remotely bring our system up to par with those.

      2. Zadoofka Florida

        Obamacare is just as twisted as the tax code. Favors Big Business/Insurance companies and craps on the needy.

    3. Lambert Strether Post author

      Singe payer is just that: Single payer. It’s a back office operation that takes the health insurance middleman parasites out of health care transations. Why do you equate removing a rental extraction scheme with “central planning”?

      I might also add that in a perfect world, we’d be comparing central planning by a few rapacious insurance oligolies with a health care system under some semblance of democratic (small d) control. If you prefer the former, why?

    4. Ian Welsh

      Central planning always fails? Canada’s centrally planned health care system is far better than America’s. Cuba’s, despite being far worse funded, is not much worse. In fact central planning often works, it just depends how you use it and for what.

    5. hunkerdown

      The AMA’s had just such a price-setting panel, or as close as you can get to it without raising antitrust concerns, for years, and they will continue to have it, and it will continue to be the standard.

      Central planning’s done just fine for the economy. At least, the important people’s economy. You’re just livestock, a cost center.

  11. myshkin

    This essay prompted me to check the progress of DC’s exchange, promising to be up and running by October 1, 2013. The site is complex, not intuitive or simple to use, has no substantive structure reflecting what the exchange will ultimately look like, just vague paragraphs describing the exchange, navigators and what is to come. DC is Obama friendly territory and will likely have one of the better exchanges, yet to date it does not appear to be user friendly.

    Fortunately my wife and I will return to Canada soon, after 11 years in this mad and maddening country and will be eligible for coverage by a provincial plan. Canada’s health care is universal but each province has its own system that is subsidized by the feds. Wealthty BC requires a minimal premium payment for those who can afford it, impoverished Nova Scotia’s coverage begins immediately and requires none. There are provincial differences but I remember my experience as a new permament resident recieving my Ontario Health Insurance Plan (OHIP) card and the ease of accessing medical care it afforded, miraculous for an expat from the States.

    I know NC derides the ACA and there is much to despise in it, and about how it came to be. I supported Kucinich, a lost cause eliminated in the primaries, I have also voted for Nader and supported all those whose univeral approach to health care and opposition to America’s war machine and its oligopoly seem forever doomed to defeat by TPTB.

    That said and additionally, that Obama has met and descended beneath the low-end expectations that the left suspected. Robert Fitch described Obama’s origins in Chicago politics and correctly drew his prescient conclusions early on. I suspect that the ACA was the best Obama could get, Max Baucas and his ilk of Democratic quislings were heading committees whose hearings I listened to ever more infuriated. Obama might have used the bully pulpit of the presidency to fight the Republicans and the blue dog Dems but I don’t think it would have gotten us any closer to universal health care.

    LBJ’s argument for pushing legislation that was flawed was that it needs to become law first and improved over time. The danger, as Lambert has pointed out, is that ACA may be so flawed it will not survive to reach ever more perfected states in the future. It may be so flawed that it will set back universal payer irremediably for the foreseeable future. There are however indications that premiums will come down, that some states will move toward universal payer systems, Vermont and possibly California, maybe Oregon too. In a desultory way the US may follow the path that Canada took, province by province, to a universal system.

      1. LizinOregon

        I was assuming that you use the exchange of the state where you live rather than where you work which would put most congressional staff in the VA or MD exchanges. It is an interesting question.

  12. nycTerrierist

    Among the many thing that gall me about O’s
    misery profiteer bailout plan is this:
    We are trending toward a precariat of freelancers
    who often can’t predict what our income will be
    several months out.
    Are we freelancers supposed to shop for so-called healthcare
    (that is, a junky insurance plan) every time our income level waxes and wanes?

    1. Lambert Strether Post author

      There is a grace period of IIRC 60 days, but after that you have to report your changed income to the Exchange adjust to whatever new regimen the eligibility engine spits out.

      1. nycTerrierist

        Thanks for the reply (and the excellent posts).

        Reporting fluctuating freelance
        income every two minutes — even with the grace period…
        is as creepy as it is burdensome (and let’s face it, depressing in this crappy economy).
        What could possibly go wrong?
        Big brotherish to say the least.

    2. petridish

      Worse than the unpredictability of income is the unpredictability of future medical needs. It’s simply impossible to adequately “insure” oneself against unknowable risks. This one simple fact demonstrates the utter unsuitability of “insurance” as the vehicle for “healthcare” access in a country that thinks of itself as “great.” Or any country, for that matter.

      Obama frequently touts the “free” health and cancer screenings provided for in the ACA. Can you imagine the despair at finding out that the “insurance” policy you have stretched your budget to afford will not provide treatment for the cancer that you never thought you’d get? Obama should stick his FREE stuff where the sun don’t shine. Better not to know.

    3. Yves Smith

      I thank my lucky stars for having a grandfathered policy.

      I have no idea what my income is/was until I get my taxes done, which is usually by September the year following. I don’t know what my income in any month because it is a function of not just how much my ad services billed, but how much they collected.

      And when I was consulting, I’d make very good money on gigs, but they be a few days to a few months, and when they were done, I’d have no idea when the next project would show up. For the last 24 years I’ve been unable to predict what my income in the next month would be (also depends on how fast clients pay even when I do have a regular gig).

      I don’t see how a self employed person can function under Obamacare. It’s like Obama gave them all a huge middle finger.

      1. Demeter

        I honestly cannot see anyone, rich or poor, young or old, able to comply with the terms of Obamacare.

        The complexity of the forms will stop most people dead in their tracks. And the cost! An up-front cost for which one receives NOTHING, certainly not health care, not even an aspirin…plus the co-pays and other methods of denying coverage.

        And when the IRS gets involved, the NSA and all the data-mongers, that will be the icing on the cake.

        Then there’s the massive unemployment and under-employment, making so many citizens incapable of paying for Obamacare or the IRS penalty….so massive refusal to file any forms with the IRS as well….

        What this nation needs is health CARE, not health INSURANCE!

        1. Persephone

          Well said. There’s little else to add on the reality of this anti-citizen (inhumane) monstrosity that is ObamaCare.

  13. Joe Firestone (LetsGetitDone)

    “The bottom line, again: ObamaCare, by its very system architecture, is riddled with these nutty distinctions, these whimsical and arbitrary inflection points, where a dollar this way or that way has massive and disproportionate effects that play out with people’s health (for pity’s sake). That’s why health care should be a guarantee — and although Obama occasionally nods to universality, he’s very careful not to deliver it — and a clean and fair system like single payer Medicare for All is the right way forward.”

    Lambert, I understand your main purpose in this post was to show the unfairness of Obamacare due to its “bucket system” from a cost perspective. That’s important.

    But even more important is the opportunity cost both in lives and in costs for the American people. I’ve estimated the opportunity cost in lives here: http://www.nakedcapitalism.com/2012/10/neoliberalism-kills-part-one.html It’s in the hundreds of thousands of lives and is unconscionable when we consider that the primary motivation for not doing Medicare for All was to bail out the insurance companies rather than destroy them.

    On cost, the article you link to at pnhp cites Gerald Friedman’s study estimating savings of $1.8 Trillion in savings over a decade if enhanced Medicare for All were passed. While Friedman’s study is careful, it seems to me to be too careful, in the sense that it examines existing cost categories, then makes quite conservative assumptions about probable savings and then adds them up to get its global figure for savings over 10 years. This approach assumes that Medicare for All, in changing the whole funding environment for health care would not have immediate and strong impacts on costs in the various categories examined. I don’t think such an assumption is justified and that such a basically arithmetic approach to savings doesn’t take into account the experience in other nations.

    Also, the approach severely underestimates likely savings and therefore severely understates the cost case for Medicare for All. It’s another case of “loser liberals” shooting themselves in the foot, by trying to be too “objective,” and not overly negative toward the other side of an argument. Sometimes doing that means that you’re actually losing objectivity in the process.

    I prefer a more normative, top-down approach to making the cost savings case. Specifically, assuming that HR 676 could have been passed in the Spring of 2009 and implemented by January 2010, if Reid, under pressure from Obama, had gotten rid of the filibuster in January of 2009; and also assuming that there’s no reason to believe that the US couldn’t bring down its Medical costs to the same percentage of GDP we find in Canada, we have the following estimates.

    Medical spending in the US, public and private, from 2010 – 2013 is averaging about $2.7 Trillion per year. That’s about 18% of GDP over that period. Meanwhile, Canada’s spending about 12% of GDP under Medicare for All. Assuming, we could have had that 12% here, we get cost savings of $800 B per year. That means we could already have saved, during the past 4 years, $3.2 Trillion, dwarfing Friedman’s savings estimate for a full decade.

    Further, from 2014 to 2023, there’s no reason to believe that the ACA would drastically cut the the percentage of GDP we spend on health care. I’ll assume ACA stabilizes this percentage, so that it’s no longer growing (call it my attempt to be “nice”). I’ll also assume that Medicare for All would stabilize costs at 12% of GDP and will use CBO projections of GDP over that period.

    So, now we have total medical costs under the ACA averaging $3.84 T per year over the decade, and total costs under Medicare for All averaging $2.56T. That’s a difference of $1.28 T per year on average, and cost savings over a decade of $12.8 T.

    Note, that these are basically “back of the envelope” calculations. I haven’t tried to adjust for likely inflation, and I may be wrong about the ability of the United States to duplicate Canada’s success in managing Medicare for All.

    There may also be other errors in my assumptions. However, the magnitude of the differences between my admittedly imprecise treatment here, and Friedman’s results suggests that the differences in what happens when you 1) use a top down approach rather than a bottom up one; and 2) try not to be too concerned about appearing to be “conservative” are worth looking at if one wants to make a political case for Medicare for All.

    Finally, I have to say that, out of an abundance of caution, Professor Friedman has gone way off base and that his results should not be cited favorably and uncritically, because to do so is to weaken the case for Medicare for All. Why is it that I never see rightists holding back on their arguments, and that it always seems to be the “progressives” who are doing that?

    1. Lambert Strether Post author

      Thanks. I appreciate the additional information on costs, but I’m really attacking ObamaCare from an ethical perspective: Fairness, equity. The bucket approach intrinsically cannot deliver equitable results.

      There is also the tactical aspect: When the ObamaCare PR machine gets rolling, we’re going to see lots of heart-tugging stories about how this or that person got helped — and they’ll be true, as stories, since a program as big as ObamaCare has to help some people!

      So, when, as in the primaries, when the Obots deploy the “Why do you want my [sister|wife|child] to die?” talking point, I want to be able to say “I want everybody to have the same care your sister got. Why do you want them to die?”

      The money case has been made, and made well, but for whatever reason it hasn’t “taken”; perhaps the ethical argument will.

      1. Joe Firestone (LetsGetitDone)

        Thanks, I recognized the fairness case; but it was fairness in the context of unconscionable variations in what it would cost people to get insurance.

        On the money case, most of the mainstream and even the fringe mainstream like the New Deal 2.0 and UMASS economists and policy analysts don’t make the money case well enough at all. Take Freidman his case is $180B in savings per year. That’s peanuts compared to $1.28 T per year.

        The very cost high savings case for people has been made only by myself as far as I can remember. So, perhaps the cost savings appeal might be more successful if others would join in at the higher level.

        Even more, if we combined the fairness, cost savings, fatalities, bankruptcies, and family breakup talking points maybe we’d finally get through the screens and get that movment for Medicare for All off the ground.

  14. TK421

    I still can’t figure out what an Actuarial Value is. Apparently everyone in America must now become an actuary to understand this program.

    1. petridish

      I’m having the same problem.

      I think it refers to the insurance plans being 60/40 or 70/30 etc. I guess people will think that if they buy a 70/30 plan for instance, the insurance company is promising to pay 30% of their medical expenses and they will pay 70%. Straight arithmetic–I buy $100 worth of healthcare, insurance pays $30, and I pay $70. The 70% out-of-pocket expense comes in the form of deductibles, copays and coinsurance, is front-loaded and calculated over a specific time frame (probably annually since deductibles are annual.) I don’t know if the premium is counted, I’d guess not.

      “Actuarial value” means that it’s NOT strictly arithmetic and individual, it’s based on “assumptions” about “standard populations” (whatever the definitions of those are.) “Assuming” that a person who buys this policy consumes the “standard” amount of healthcare in a year, it will work out that the insurance company has paid 30% of the expenses and the individual has paid 70%. It could be more or less depending on how closely the healthcare you consume conforms to the standard.

      As always, the devil is in the “assumptions” about “standard populations” which are made and defined by the insurance companies. These “assumptions” are unknown as is their relationship with reality. The “assumptions” and “standards” are memorialized in the insurance policy as “covered expenses.”

      OK, I’ve been cogitatin’ on this all morning. Will those of you who really understand actuarial values please weigh in?

      1. Yalt

        It’s actually quite simple.

        First, a goal is set for the result of the calculation. In this case, the goal is presumably the maximum possible actuarial value that can successfully get through a state insurance regulatory body that’s probably going to be lenient because it’s run by a political appointee who looks forward to lifetime employment with your insurance company when he steps down from his post.

        Then, a number of possible sets of assumptions are analyzed. That set that results in the maximum actuarial value subject to the constraints mentioned is chosen, any record of consideration of the other possibilities is destroyed, and a written argument is prepared justifying the chosen set of assumptions as the only reasonable set that could be made.

      2. Ms G

        “The 70% out-of-pocket expense comes in the form of deductibles, copays and coinsurance, is front-loaded and calculated over a specific time frame (probably annually since deductibles are annual.) I don’t know if the premium is counted, I’d guess not.”

        I don’t think this is right, though I’m certainly not an actuary (nor is Obama or Sebelius, come to think of it!).

        My read is that the 70/30 is the “cost-sharing” that applies only ONCE THE POLICY STARTS TO PAY. That is, Obama Product only pays $70 (and you pay $30) only after you have paid your deductible in full (as to whatever category of care is at issue — because there are splits on whether deductibles apply to x, y or z product/service/procedure — another sub-excrescence of buckets).

        Nor does 70/30 apply to the premiums.

        The only “sharing” at the premium level occurs if you qualify for a subsidy and for that you got back to the grid of “poverty minus 1” or “poverty + 100%” or “pverty + 200%” etc.

        I think the confusion about what “60/40” or “70/30” means (i.e. which money payment stream does it apply to) is a natural product of the Obama PR Campaign which is doing its level best (understandably) to maintain opacity as to the REAL COST of these Exchange Products for the end-user.

  15. EMichael

    Couple of things here as I watch progressives continue to eat their own.

    The GOP stopped single payer.

    If the ACA is successful, the way to universal, single payer healthcare be open. If the ACA is not successful, or its success is pr’ed into a failure, the way to universal, single payer healthcare is blocked for our lifetimes.

    Pick a side. Make comments and suggestions on improving the ACA. But don’t forget which side you are on.

    1. Lambert Strether Post author

      Wrong. The Democrats destroyed single payer in the process of adopting RomneyCare, orginally designed by the Heritage Foundation for the express purpose of heading off single payer, and rebranding it. Things didn’t have to be that way: In 2009, the Democrats controlled the Senate and the House, and The Greatest Orator of Our Time was in the White House, with a mandate for “hope and change,” and the Republicans were completely discredited. There were also single payer bills written and ready to go: HR676 in the House and S703 in the Senate. Even if the Democrats didn’t pass the bills at once, they could have bypassed the Republicans entirely, either by abolishing the filibuter when the Senate first convened, or by reconciliation (which is how ObamaCare ultimately passed anyhow). The Republicans were relevant only because the Democrats allowed them to be relevant.

      What happened instead: The Obama administration pushed ObamaCare, allowing Liz Fowler, an insurance company executive on secondment to Max Baucus’s office as chief of staff, to draft the bill. The Democrats did not bring the single payer bills forward, even going so far as to censor a single payer question from the record of one of its kayfabe town halls.

      Meanwhile, the “progressive” blogophere — funded in part by Obama-friendly national union offices like the SEIU — played, with very rare exceptions, a disgraceful role in running interference for Obama, not only by silencing and suppressing single payer stories and advocates, but by helping the administration run a bait and switch operation for the so-called “public option” — an ever-changing series of talking points promoted by policy entrepreneurs like Jacob Hacker — that sucked all the oxygen away from single payer before quietly expiring when it has served its purpose. (The cream of the jest is that Obama had cut a deal, in private, with Big Pharma that there would be no public option, but the “progressives” went on advocating it in public for months afterward. Whether the “progressives” were in on Obama’s con job, or just not as “savvy” as so many of them claim to be, is still an open question.)

      All in all, the ObamaCare story is a classic illustration of how Obama is “the more effective evil.”

      As for sides, I’m on the side of all citizens, who should be guaranteed equal access to health care. Which side are you on?

      As for tactics, the only way forward for single payer in the ObamaCare frame is for states to be permitted to experiment with single payer themselves, for which ObamaCare demands they get a waiver. Waivers are not available until 2017. And the way to justify the single payer waivers is to keep relentlessly pointing out the pile of crap that ObamaCare is, and that the American people deserve better.

      1. EMichael

        YOu have no idea what you are talking about.

        ” Connecticut Sen. Joe Lieberman, who was formerly a Democrat but who is now an independent, announced today that “if the bill remains what it is now, I will not be able to support a cloture motion before final passage.” In other words, Lieberman will support a filibuster. “I can’t see a way in which I could vote for cloture on any bill that contained a creation of a government-operated-run insurance company,” Lieberman said.

        One largely unspoken assumption behind Reid’s quest to get an “opt out” version of the public option through the Senate is that he doesn’t really need 60 votes for the health reform bill itself. He just needs 60 votes for the cloture motion prior to final passage. Once a filibuster is cut off, health reform can pass with 50 votes (the 51st being Vice President Joe Biden, president of the Senate). One reason Reid’s gambit looked so promising as recently as yesterday was that Lieberman, despite his previously stated opposition to the health reform bill even without a public option (i.e., as passed by the Senate finance committee), had agreednot to support a filibuster against it. It now appears that Lieberman either changed his mind or was misunderstood.”


        1. Yves Smith

          This is the best you can do? A mere huff and puff threat of a filibuster from a single Senator? Oh come on.

          You Obots are gonna have to do better than that. The Bernanke nomination for his current term not only had 5 holds, it actually WAS filibustered. And guess what, Obama got Bernanke through. Obama had to break a little sweat and lobby personally for Bernanke the weekend before the vote.


          All that Lieberman threat meant is Obama would have to have arm-twisted him a bit or given him a bright shiny toy had he been willing to pursue single payer or go the procedural route.

          The fact was that single payer never was even remotely on the table. Obama killed efforts from within the party to put it forward.

          It’s just flat out false to pretend that where we wound up is due to some evil Republican plot or inherent obstacles. This is the health insurance system Obama wanted and he got it.

          1. run75441


            Yes Obama could have prevailed and forced Congress to rewrite the PPACA; but, it was Liberman who sunk Single Payor and Medicare for those over 50.



            The Senator from Aetna would have joined the Repubs and filibustered. You know as well as I do, the Blue Dogs and Lieberman were angling for their own special interests.

            Lieberman said of the Medicare proposal, “Though I don’t know exactly what’s in it, from what I hear, I certainly would have a hard time voting for it because it has some of the same infirmities that the public option did.

            “It will add taxpayer costs. It will add to the deficit. It’s unnecessary,” he added of a provision that Senate Majority Leader Harry Reid last week hailed as part of a breakthrough between liberals and moderates.

            1. Joe Firestone (LetsGetitDone)

              The President took enhanced Medicare for All off the table very early in 2009. This is widely known among progressives, and is the reason why most of the “village” progressives in DC began to support the Public Option after years and years of support for Medicare for All.

              As far as the PO is concerned, the President took that off the table in the late Spring of 2009, when he failed to support even the very weak PO bill that came out of the House Committee process. Thereafter, he supported a full-on insurance company bailout which eventually became PPACA.

              At the time of its passage I predicted that PPACA would come nowhere near producing coverage for the 30 plus million additional people promised by the Democrats at the time. This prediction is being borne out now, as we see many States refusing to implement the Medicaid portion of the bill, and implementation of the other portions of the bill going forward with painful slowness.

              As far his inability to get Medicare for All through Congress, I think that claim is a rationalization. If the President had asked Harry Reid to organize the Senate in January 2009 without the filibuster, I think Reid would have bowed to the will of the President who was at the height of his popularity in a time of true national crisis. In addition, the President could have discreetly mentioned Reid’s upcoming re-election attempt in 2010 if he needed to exert any more pressure.

              Without the filibuster, the President could have gotten Medicare for All through with 50 + 1 votes in the Senate. In the House, Nancy Pelosi would have done anything the President wanted, so he could have easily passed it there.

              Had he passed a stimulus bill twice as large as the one he passed, and followed with Medicare for All, there would have been no tea party movement, and no defeat for the Democrats in 2010. The only question is whether Obama blew his chance to be a hero out of incompetence or deliberately because he wanted to please his contributors.

              My own answer is that he works for Wall Street and has always done so. That is the one consistent theme in his economic policies. When it comes to deciding fiscal or legal questions, he never decides them in favor of most of the people. he always takes care to see that the FIRE Sector and big businesses of various kinds get new opportunities for profit. Mr. Obama approaches George W. Bush, and exceeds Ronald Reagan in the extent of his dedication to neoliberal principles of economics, and He is far more conservative in his economic policies than George H. W. Bush.

            2. deconstructingpoliticalspin


              Joe F is correct.

              The Dem Party has largely become the Party of “FIRE,” much as the Repub Party is the party of “Big Oil.” [Eg., 1999 repeal of the Glass-Steagall Act.]

              And it’s not just the ACA.

              Check out the USA Retirement Fund “scheme,” concocted by Democratic Senator Tom Harkin. (He’s already received awards from the insurance–annuity and public pensions–industry for his “contributions.”)

              The ACA set a terrible precedent for “mandating” the American People to purchase insurance products.

              Initially, the USA Retirement Fund will be an “opt out” plan (as best as I can determine, since many articles on this plan are pay walled). And I’ve read articles that describe it as “mandatory.” So, I’m not absolutely certain how it will be initially enacted.

              I will continue to try and ferret out info on this proposed bill. He’s generally rather vague when he talks about his proposal. I’ll try to relocate and post a video of him introducing his plan, if and when it comes up for a vote.

              What we really need is to significantly increase Social Security benefits. And I believe that Senator Harkin may be calling for a small increase. Which is good, but not enough.

              But the “hybrid” plan that he describes that puts the most risk squarely on the individual, is not the best solution in regard to helping Americans who do not have a “defined benefit” pension plan.

              Senator Harkin hopes to have the USA Retirement Fund bill passed and implemented before he retires. So I suppose that we’ll find out “the particulars” soon enough.

              Don’t know if the link below will work, but here you go:


              Another gift to FIRE.

        2. Lambert Strether Post author

          I show how to avoid the filibuster at the start of a session, or to use reconciliation, which was, ultimately, used, and you point to Lieberman threatening a filibuster late in the session? Do you have a concept of how to respond to an argument in an on-point way?

          Please, do NC readers a favor. Talk to your supervisor, ask to be benched, and tell them to send in a varsity player. Deal?

      2. Jeff W

        The cream of the jest is that Obama had cut a deal, in private, with Big Pharma that there would be no public option, but the “progressives” went on advocating it in public for months afterward.

        Not only “progressives” but President Obama himself.

        Apparently, the fix was in—in backroom deals with both the hospital and pharmaceutical industries—sometime that July, 2009.

        On 15 August, at a town-hall-style meeting in Grand Junction, Colorado, Obama both “strongly defended” the public option, according to the New York Times, and downplayed it, saying ““This is just one sliver of [health care reform], one aspect of it.” (I recall, at the time, hearing that word sliver and just knowing that we were being played.)

        On 9 September, Obama went before a joint session of Congress and blathered on a bit about the public option: “But an additional step we can take to keep insurance companies honest is by making a not-for-profit public option available in the insurance exchange.” The White House transcript notes “(Applause)” after that line.

    2. Code Name D

      Why do i have to remember which side i am on? This is not Obama right or wrong here. The ACA should stand or fall onits own marits, and i dont think it can.

      And how do you think that ACA successeding will lead to singel payer. Obama him self basically says this is the last reform healthcare will ever need.

        1. petridish

          If the ACA fails, the medical insurance industry will fail. If the medical insurance industry fails, the rest of the medical-industrial complex will fail. If you need reminding, that industry is 18-20% of GDP.

          You’re either very old, or you’ll see this issue come ’round again.

        2. Onemoretime

          If the ACA fails it will be about a decade before an administration tries healthcare again. That is slightly less than the time it took Obama to try healthcare after Hillary was shut down.

          Healthcare is too important to the majority of Americans. After about a decade of unequal outcomes and basic failure of the legislation there will be enough outcry from voters to revisit it again and possibly get it right at that time.

          There are similarities with the financial crisis. Very few people believe Dodd Frank has done anything to prevent a crisis from happening again in the financial sector. (For pretty much the same reasons). So when the next crisis hits the current resistance to common sense (Volcker rule) will be much more acceptable, maybe.
          The new democrats are currently eating their own. Progressives seem to be coalescing around a minority in the democratic party that holds true to their traditional base of which it is quite apparent Obama is not a part of.

          1. run75441

            1993 was when a healthcare bill written by The White House came to the floor at 1/5th the cost of what it will be with the PPACA. The PPACA was written by Congress, a partisan Congress with the Republican sitting out. If this fails a deacde or two will pass as the Teabaggers will block the House which they could not do when the PPACA was passed.

            1. Lambert Strether Post author

              Wrong. ObamaCare was (as I indicate above) drafted by Liz Fowler, a Wellpoint VP on secondment to Max Baucus’s office as his chief of staff. (She later went on to the White House and then through the revolving door to Big Pharma.)

              When you write “the PPACA was written by Congress,” you obscure the crucial point that PPACA was written by an insurance industry insider — whether out of sheer ignorance or tendentiousness I don’t know.

        3. Lambert Strether Post author

          Why do you believe that? You can’t, on the one hand, argue that there’s the political will to make constant improvements to fix Obama’s bugs, and then argue that there’s no will to install a better system entirely. You also ignore the efforts for single payer systems at the state level, which is how Canada got single payer.

    3. Ms G

      When you say “progressives eating their own,” are your referring to how the Career Progressive Class(*) has thrown real progressives (the 99.9% with no false consciousness) or something else? Because it’s not so clear.

      (*) Starting with DLC and its “media” organs in the webisphere, such as MoveOn, et al.

      1. Ms G

        “has thrown real progressives under the bus” (last 3 words should be added to original post)


  16. Ian Welsh

    Perhaps more to the point, even at the top level, you’re paying more than 2K for insurance. If you’re earning 18K, I’m sorry, you can’t afford that 2K, especially since the care you receive is shit.

      1. nycTerrierist

        If this doesn’t stir the comatose sheeple, what will?

        Good thing the police state is prepared for any ‘whiners’ who don’t want to ‘eat their peas’…/s.

        What a mess.

      1. Lambert Strether Post author

        See the caveats on the calculator — especially the fact that Actuarial Value means that not all Silver plans are created equal — but sure. You’re assuming that health insurance means health care — and since insurance companies are in the business of profiting by denying care, that’s always a dubious assumption in any given case — but I’ve never denied (and in fact explicitly say) that ObamaCare’s going to help some people (and, as I’ve shown elsewhere, people who are likely to be Obama voters). What ObamaCare cannot do is treat all Americans fairly by giving them equal access to care. And by design.

        * * *

        Thanks, however, for flagging the tactic Obots are going to use (“Such a deal!”) going forward. Particularly the lying, since (again, see the caveats) the calculator does not say what you say it does. I don’t know about you, but a few hundred dollars either way on these estimates could make a big difference to some people.

        1. EMichael

          Hey, I can only go with the best source I have. Then again, not a chance in the world such an individual could get anywhere near the coverage, or the cost, of health insurance before the ACA.

          Strangely enough, I know many hard rwers who are suddenly finding out the ACA will greatly help them with their insurance. All small business owners who will get off their high deductible plans for less costs.

          1. run75441

            You are playing Jazz in a Country and Western bar. It ain’t gonna play here. I agree with the comment, healthcare will not come out of Congress again for at least a couple of decades. Hillycare was attempted in 1993. Because it did not originate in Congress, it failed. Almost 20 years passed before healthcare was attempted again and at a far greater cost.

            1. Joe Firestone (LetsGetitDone)

              “Hillycare was attempted in 1993. Because it did not originate in Congress, it failed.”

              No this was the lesson, the Clintons drew from their defeat. They wanted to blame their failure on process rather than substance. The reason why it failed in Congress was because it was an incredibly complex bill that was easily subject to distortions and lies opponents could tell about it in their ad campaigns. If the Clinton had pursued enhanced Medicare for All back then and written a 35 page bill that everyone could understand. I think there would have been no Harry and Sally, or whatever the campaign was called around to defeat it. You see, everyone knows about Medicare and what it is. If you propose enhanced Medicare for All and say to people it’s like the Medicare you know about but better, because it covers dental, psychiatric treatment, chiropractic, and also has no co-pays, It would be very hard to lie about and confuse people. You can say it’s socialized medicine, of course, but that’s easily answered by saying hell, all the providers outside the VA will be private, period, end of story. of course, there will also be no more insurance company death panels to deny you coverage when you get sick. What can I say? It’s a winner!

              Unfortunately, the smart alecky Clintons wouldn’t try to pass Medicare for All, and neither would Mr. political genius Obama who preferred to bail out the insurance companies.

          2. Joe

            Speaking of not a chance in the world: Do you actually think some one struggling to survive on $18k/year can:
            a) Afford to spend close to another $1k/year all of a sudden because some one says so?
            b) Will be able to afford the deductibles that the silver plan contains?

            Any one making $18k a year in 2013 is struggling to feed themselves let alone have any extra left over at the end of the month. The people that make these idiotic decisions have no clue what it is like to live on starvation wages.

            1. run75441


              The people who made these decisions are you local Congress Persons and Senators. Feel free to call them and rip them a new asshole. I do it with Mikie Rogers and I also give State Senator Joe Hune a reaming every chance I get.

              So what is the alternative Joe, Nothing? The employer, if they had healthcare insurance, would be charging something similar with fewer benefits.

                1. Lambert Strether Post author

                  Ooh, an Obot tag team! Show that ObamaCare provides equal access to health care for all citizens, please. That’s the point of the post. Or admit it doesn’t, and you’re OK with throwing X percentage of your fellow citizens under the bus.

                  1. run75441


                    With all due respect, I doubt there is anything which could convince you otherwise which makes it senseless to continue a discussion with you.

                    1. Lambert Strether Post author

                      Like I said: “you’re OK with throwing X percentage of your fellow citizens under the bus.”

                      You can’t win the argument, so you make it about the other guy. Well done. Oh, and the “with all due respect” move takes a lot more cred than you’ve built up here so far.

              1. Lambert Strether Post author

                The alternative is not to “rip them a new one” (pleasant though that task is) but to advocate for single payer waivers at the state level. It’s also important to relentlessly point out flaws in ObamaCare as written, both to support the drive for waivers, and to create pressure to fix the flaws (though ObamaCare’s flawed system architecture makes it fundamentally unfixable).

                I assume you’re doing all that, in addition to trolling coment threads?

              2. Joe

                My representative in congress is a dim witted tool named Dr. Paul Braun. Somehow this moron was able to get a doctorate in medicine while denying the validity of evolution. Also, this denier of basic science is Chairman of the Investigations and Oversight Subcommittee for the House Science, Space, and Technology Committee.

                This is who I’m supposed to turn to for support and or help? A man with a doctorate in science that believes that the earth is no more than 2000 years old?

                Also, regarding the premiums you and the other Obamabot are quoting are as useful as your other talking points. This is a quote from the cost calculator that was linked in an earlier post “Your out-of-pocket maximum for a Silver plan (not including the premium) can be no more than $2,250”. So the person making 18k a year has to come up with $3000 per year before he/she gets one iota of actual benefits.

                The question is and remains: Do you actually believe that someone that makes 18k/year can afford this? What do you think that someone who makes 18k/year nets after taxes?

                I’m not sure why I bother, I’m probably talking to an algorithm.

          3. Ms G

            “Then again, not a chance in the world such an individual could get anywhere near the coverage, or the cost, of health insurance before the ACA.”

            If such an individual can go personally bankrupt due to health care costs just as much under ACA as under “health insurance before the ACA” what exactly has been achieved here? It’s a rhetorical question.

          4. Lambert Strether Post author

            Hmmm. If it were easy for you to cite to any RWers who felt that way, I am sure you would do so. Hence your resort to unprovable claims. Smarter Obots, please.

        2. Lambert Strether Post author

          To repeat: “What ObamaCare cannot do is treat all Americans fairly by giving them equal access to care. And by design.”

          The Obots don’t contest this. Therefore, they agree. I’m glad, because that’s the point of the post.

  17. Ms G


    The fraud that is ObamaCare is embedded in its “nom de signature project.”

    The Act is targets customers (marks), it does not serve “patients”

    The Act protects insurance companies (not “patients”, or consumers, or marks)

    The Act — most relevant to this (most critical) discussion — creates “affordability” definitions that (in the real world of the 18K/year gross etc.) are bankruptcy-inducing for those who were unable to afford insurance in the first place and are now fraudulently being lured with false (but so easily unmasked) claims of “affordability.”

    The Act perpetuates and reinforces the centrality of Insurance and its monopolistic rent-seeking business model in health care. As a result, the Act has nothing to do with delivering health “care” but everything to do with delivering a captive market to insurance companies.

    Basically, the only accurate word in the title of this misbegotten and disgraceful legislation is “Act” — as a neutral noun and also as a signifier that this law is the opposite (in word and mechanics) of what it claims to be (in the Obama PR Echo Chamber, etc.)

    1. run75441

      Ms G:

      You have been drinking too much of the kool-aid. Where can you get comphrehensive coverage today at $60-something a month? and have a cap on out of pocket? and get free preventive care?

      1. Lambert Strether Post author

        First, define “comprehensive coverage.” Oh, that’s right, there are no plans, only proposals, so all we have to go on on is Obama’s propaganda. Second, show that all citizens have equal access to equal coverage. That’s the baseline the post sets. Smarter Obots please.

      2. Ms G

        I’m in a 12 Step program for Kool-Aid abstainers. Sorry you were confused. In any event.

        Come October 1, you will please post a real life scenario where someone is paying $60/month with no-deductible and full coverage of any medical procedure or visit or device that is necessary. It will be interesting to see whether such a real-life scenario materializes — especially if the “lucky guy” or “lucky girl” is a 27 year old health, non-smoking, non-obese person who has never been to a doctor or been sick.

        Good luck with that, dude.

        Lambert suggested you talk to your supervisor so someone more skilled at spamming could take over for you. (Or maybe it was for your buddy there who’s also working over time on here — an honor, to be sure!)

        Take the advice — it was excellent.

        Now go have a micro-brew at your local bistro. Tx, Goodnite.

        1. Ms G

          Also, let us know about the great dental coverage that will be provided by these awesome Exchange Products. It’s been a long time since braces, but dental care is a bitch (super costly) and has a way of just demanding to be taken care of (despite the actuarial requirements of insurance companies).

  18. Elliot

    @ Lambert: I would like a citation please on the being forced into medicaid if over 55/under x% of poverty level…and being denied the out of buying a policy on one’s own (crappy or not). I happen to be in that bracket, and the state exchange is not up and running yet, so there is no way for me to check that.

    What I have found currently is that the new mandate gives me access to coverage I did not have before with my bare-bones policy, for preventative care which in the past I have always had to forego or pay full bore for.
    I can ill afford the policy, even though it is a skosh cheaper than the old one; but I cannot at all afford the cost of, say, being hospitalized after being in a car accident or developing some expensive illness. So I pay.
    *makes sign against the evil eye*

    –>> Are you saying that this policy will be unavailable to me as of Oct.1, or Jan 1? Or that they will ignore the policy in force and flip me anyway? Please, a link to something I can call my insurance company about.

    1. Lambert Strether Post author

      Here’s the link. Try the Kaiser calculator. NOTE WELL that situations differ according whether you are in a Medicaid expansion state or a non-Medicaid expansion state — yet another way that ObamaCare’s horrible system architecture has ended up treated citizens unequally.

      1. Ms G

        They’re still here at 10:21pm. The post has evidently hit a nerve. Great stuff. And it’s good to know the arguments from Enroll America are as flimsy and transparently mendacious as demonstrated here by today’s Obot Bobsy Twins.

        1. Lambert Strether Post author

          Hmm. I think that was a legitimate question; anyhow, I treated it as such.

          One of the uncovered stories of the transition to ObamaCare is that a lot of people have cobbled together coverage solutions that work for them after a lot of experimentation and trouble — this policy, this doctor, this treatment or medication — and they’re very understandably worried that ObamaCare, even if we grant it’s a good faith program (which I do not), is going to disrupt a situation they’ve worked hard to achieve and which they have a lot invested in.

          So I read Elliott’s comment that way.

          1. Ms G

            Yes, the untold story to which you refer is hugely important. The cobbling together … something that won’t go away with ACA plans … same nonsense with hmo networks, trying to pick a policy that includes one or two of your existing doctors … then finding out whatever, and you’re not covered anyway. Ugh x 10000000000.

            If Eliot’s question was in good faith I owe him an apology.

          2. Elliot

            You read me exactly right, Lambert. And thanks for the link.

            Thing is, medicaid care in this state is crap, the docs are bottom of the barrel (when you can see them), many docs refuse to see medicaid patients, the formulary is crippled, privacy is zero, and you don’t get to see the doc you want if you do find one who is not an idiot. You get stuck with PA’s who should never have graduated who know less about medicine than a first year chem student.

            And I have indeed through much searching found a *real* doctor, who does not throw extra tests at me for the $ benefits to him, and like Yves, I can in no way be sure of my income…farming and all that. So the cruelty of bad care multiplies itself with intrusive constant reporting of income, while the frigging congress and staff get to go first class. I am by turns frightened and bitter.

            My old policy… it was so old I was almost the last person on it.. did not cover much, but the split was 80/20, and a gamble I could take.. the new plans that cover more are sometimes as bad as 50/50… which must be another of the ways they are paying for the ONE preventative care visit, and the ONE yearly visit, that are paid for by my new plan, which is 80/20 (and I had to argue with everyone to go for that rather than the others)…however long it lasts.

            So this is not me kissing Obama’s butt for this monstrous healthcare plan, this is me hoping to find one good thing in an increasingly dire situation.

            —I did find one other good thing; my state did not expand medicaid. Which feels gaggy to say.

            But everyone I know, on both sides of the political spectrum (except industry drones) is praying for Obamacare to fail, as it is so much worse than what we had. heck even my insurance agent says single payer would be better.

    2. Ms G

      You might also want to try one of those 800 numbers that HHS has published for people who have questions about the PPACA. There’s a twitter feed as well — you could give that a whorl.

  19. Elliot

    Gracias, LetsGetItDone.

    —here’s an idea to think on: for those of us who own our homes and have gardens (a rarity now I know)– obamacare seems designed to force us to look for more jobs than we already have… no more getting by as it suits us.
    They’ve taken a page from the english driving the irish and scots off the land.

    And while I have never had to endure food stamps/Snap degradation at the hands of other shoppers at the grocery store (see: garden/farmer)…… look for a similar disdainful treatment of even more of the population that gets rolled into medicaid.

    This cannot go on forever; a parasite that kills the host–well, it kills the host. Eventually (and I don’t want to think about how we get there) either obamacare will fail, or be overturned. Misery ahead any way you look at it.

  20. Lambert Strether Post author

    Once more: “What ObamaCare cannot do is treat all Americans fairly by giving them equal access to care. And by design.”

    The Obots don’t contest this. Therefore, they agree. I’m glad, because that’s the point of the post.

Comments are closed.