ObamaCare Staggers Toward the October 1 Finish Line (3)

By Lambert Strether of Corrente.

Yes, ObamaCare, even if it has been driven off the front page by the NSA and Syria, is still lurching along; there are 23 days ’til open enrollment begins, even if October 1 has been very conveniently redefined as a “soft launch” that doesn’t really matter, the only date that really matters being January 1, 2014, when you can actually purchase the ObamaCare product, because Jeebus, who wants to make huge household budget decisions that could affect your 2013 1040 in 2013? (But can’t somebody tell HHS that October 1 doesn’t matter? Because it’s all over their site.)

The administration, as it is wont to do when faced with a tough sell, has deployed The Big Dog. The Times called Clinton’s speech “wonkish,” but, alas (rather, necessarily) it was filled with evasions and half-truths. Selecting one:

“This does give us the best chance we have to achieve nearly universal coverage, provide higher quality health care and lower the rate of cost increases, which we have got to do in a competitive global economy,” he said.

Well, “nearly universal” is what I’d call lawyerly parsing. Of the approximately 50 million uninsured, ObamaCare projects to cover only 7 million of these in its first year, and 30 million of those uninsured uncovered when fully implemented. So how “nearly” is that? I’d say not very. I’d also say that any American deserves health care just as much as any other American — we are all equal in suffering — yet this thought somehow never occurs to ObamaCare apologists like former President Clinton, who, like Obama and the rest of the political class, is ever comfortable throwing millions under the bus.

And for those who are covered, coverage is, basically, random. Luck of the draw. As the launch date, soft or not, approaches, we’re getting more detail:

Residents in Seattle and Portland, Ore., will pay $213 and $165 monthly respectively for the same lowest-cost Bronze plan, which will cost $308 in New York City and $336 in Burlington, Vt.

First, look at the sleight of hand in the phrase “the same … plan”; the benefits in the plans are the same on paper (or on the website), but “words are wind,” as they say in Game of Thrones. The plans will have different networks, different definitions for services, different delivery of services. Anybody who’s had to cobble together health care from different providers knows this; and Kaiser did a study that proves there are “substantial variations among plans,” even when insurance actuaries are given the same set of definitions for plan benefits.

So now we’ve got ObamaCare being random in two dimensions: Random because the price depends on where you live; in California, it depends on what county you live in. And random because you really can’t compare individual plans on the Exchanges, as ObamaCare promises, like flat-screen TVs: The plans are incommensurate! So Beltway triumphalism — “Get. Excited.” — that we finally have some notion of what ObamaCare will cost the average citizen — is completely misplaced: We’ve got a price, but we don’t have a product, and the price of the (incommensurable) product varies whimsically by our location. If the Post Office worked like ObamaCare, every zip code would have a stamp with a different price on it!

And why is the ObamaCare product random? And why are the prices random? Because for all the bluster about ObamaCare being universal — as we have seen, it isn’t — ObamaCare makes no commitment to universal coverage, and does not treat health care as a right, unlike single payer Medicare for All. That’s because ObamaCare is in its essence a market state solution, a splendid example of cognitive regulatory capture, where the government — using the word “consumer” instead of the word “citizen” is the tell here — adopts the private health insurer mindset, and actually forces people to buy a product, while all the while turning over the profits to corporation whose markets it made!

Perhaps that’s why, when a Democratic loyalist blog finally decides to do some education on ObamaCare, it doesn’t start with the actual benefits ObamaCare will deliver*, and certainly doesn’t mention let alone advocate for proven programs, like single payer Medicare for all, that could actually deliver the services ObamaCare claims to. No. What do they do? They begin a series that will explain the arcana of private health insurance. Good call, because that’s what ObamaCare is.** Balloon Juice:

I’m a bureaucrat at a health insurance company which most of you have never and will never hear about. My job is to be a subject matter expert on a fairly arcane set of knowledge. I have seen some posts and some great comment threads at Balloon Juice where great questions are being asked and basic mechanical knowledge would be very useful. I will be writing a series of posts over the next couple of weeks/months that attempts to explain why a profit seeking insurance company does what it does.

A project which struck me, as it struck others more tactful, as the final collapse of the “progressive” Obama supporter into whimpering irrelevance (if constitutional scholar Obama’s gutting of the Fourth Amendment with the NSA scandals and peace candidate Obama’s warmongering on Syria had not already achieved that). If we’d passed single payer Medicare for All in 2010, we would already have saved a trillion dollars and a lot of grief. So why is a putatively progressive blog explaining how the completely parasitical, rentier-driven business of private health insurance works, instead of trying to abolish it? If you’ve got a tapeworm in your gut, you don’t try mitigate it, or “tweak” it, or have a talk with it, to persuade it to devour less of your substance: You get treatment and kill it!

Finally, I’ve been saying for awhile that the ObamaCare rollout feels like a political campaign because it is a political campaign. The rollout, remember, does not target the sick who actually need care. Nor does it treat all citizens equally; instead, market segmentation is used, and only those likely to respond to marketing are targeted. And who is targeted? Well, youth — we are told that the not-yet-old must subsidize the no-longer-young*** — Blacks, and Hispanics, especially in important Democratic states like CA. At this point, a suspicious mind might notice that these demographics are suspiciously close to Obama’s demographics as a candidate. And a suspicious mind did. The LA Times:

Administration officials are also working directly with key constituent groups including Latinos and African Americans to encourage them to sign up for coverage.

So that cat’s out of the bag now.**** Maybe if I have the energy I can get to how ObamaCare is also throwing walking around money to Democratic front groups for ill-defined services, but that will have to wait for another day.

Meanwhile, just think: If we had single payer Medicare for All, maybe Breaking Bad’s Walter White — who had health insurance, after all — would have remained a prideful, resentful, ego-driven sociopath chemistry teacher, instead of becoming a drug lord. It’s a funny old world.


NOTE * Ritual caveat: A program as huge as ObamaCare will undoubtedly deliver benefits to some. However, it cannot and will not deliver benefits to all, equitably. It’s not designed to do that.

NOTE ** Which would be why Medicaid and Medicare are both left as entirely separate systems. Eh?

NOTE *** Note privatized actuarial logic, so distant from a sense of “provide for the common welfare.”

NOTE **** One does not need to assume that ObamaCare will provide real benefit even if Obama is trying to sell it (or, in this case, upsell it, his 2008 and 2012 elections having been the initial sale).

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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. sellem

    As this article states, many plans will be offered off-exchange too and some will be up to 25% cheaper than the exchange plans. Not sure what the catch is, but the article says that non profits on-exchange may offer better plans than the off exchange competitors. http://www.modernhealthcare.com/article/20130906/NEWS/309069947/analysis-indicates-some-consumers-could-get-better-deal-outside-of

    Oh and did I say H&R Block will now sell health insurance? Hopefully they will tell you how to minimize your tax penalty if you try to go without. http://www.chicagobusiness.com/article/20130905/NEWS03/130909888/h-r-block-online-insurance-broker-team-up-to-sell-health-plans

    While I’m glad that some health care e-zines are offering helpful info, it’s all dispersed among different sources and it will take a massive research project to figure out what to buy this year. Makes you nostalgic for the easy purchase negotiations at a used car lot.

  2. Pat

    There are so many lies attached to the selling of the ACA, it is hard to tell where to start. Up to the big one, that this will mean universal health care. It won’t even mean that for a good portion of the people who buy the overpriced policies, or end up on the bronze package from their employer. How many of those struggling to feed themselves and pay their rent will forgo going to the doctor because they just cannot afford the co-pay or the deductible. At least I haven’t heard any of the toadies spout the clearly delusional ‘no one will go bankrupt because of medical issues again’. I’m guessing a few got called on it, with the evidence from Massachusetts that that one is a big ole steaming pile of crap.

    I know I should be happy because of that seven million, but I still cannot shake the feeling that we would be better off in the long run if this piece of crap had never passed. That this will confirm what all the people have thought about government in health care and make single payer/medicare for all even more of a pipe dream, not increase its chances. i so hope I am wrong, but everything I see and learn tells me otherwise.

  3. myshkin

    Lambert, I’ve been following your critique of the ACA and believe that you’re perceptions are accurate as far as they go, however they do tend not to venture into a perspective that looks at health care legislation from what is possible in this corporately owned country.

    Have you ever explained how a universal health care plan might emerge from the farce of governance in Washington? Other than to make the perfectly sensible observation that opening Medicare up for all would be the logical answer, your explanation to how that would happen in the US congress where the law makers are mostly representatives from corporate America is unclear.

    My point, delusional perhaps, has been that the ACA, as deeply flawed, (perhaps fatally) as it may be, still could be the foot in the door for a universal system. Public Citizen is pushing this strategy as well, “The Affordable Care Act provides an opening for states to craft their own health care systems. It permits states to apply for an exemption from the act’s requirements beginning in 2017. In order to receive a waiver, a state would need to demonstrate that its alternative proposal would meet the performance benchmarks of the Affordable Care Act.” An excerpt from “A Road Map to ‘Single Payer’.”


    A few state governments have already embarked on this road, Oregon back in the nineties, has since gone through contortions of progress and massive setbacks but seems poised to move forward using this ACA opening to institute coverage for all Oregonians. Vermont too is on its way to a unversal state plan that taps into federal funding through a waiver from the ACA.

    It’s the way it happened in Canada, over many years, from one provincial effort, Saskatchewan’s; it may be the best hope in this troubled country.

    1. Lambert Strether Post author

      Have I ever explained? No; there are many advocacy groups, like PNHP, that can do a better job of that than I could. What I can do, and I hope, am doing, is raising awareness, which is the first step to making any change anyhow. If, every time a consumer citizen has a rotten experience on the Exchanges — and there will be million of them — and they think “There has to be a better way,” that will be the foundation of everything.

  4. petridish

    What’s been concerning me lately is use of the innocuous sounding words “sign up” as in, “Sign up to win a new car” or “Sign up for our free newsletter.”

    As we’ve been repeatedly told, “Obamacare doesn’t work unless young, healthy people ‘sign up.'”

    Use of the casual phrase “Sign up” would seem to deliberately obscure a serious reality–you are signing a CONTRACT and making a specific FINANCIAL commitment.

    You could be in for quite a shock if you “sign up” casually, underestimate your income (to get a larger subsidy) and then get the IRS breathing down your neck to pay back the extra money you “fraudulently” accepted.

    Just as with all those fantastic mortgage deals, this has a, “‘Come into my parlor,’ said the spider to the fly” quality about it.

    1. nycTerrierist

      Exactly. Sounds like a nightmare – which is is –
      especially for freelancers with fluctuating, unpredictable
      incomes. With more and more of us in the freelance precariat, this will be yet another source of hardship and grief.

    2. diptherio

      Actually, I’m more worried about the folks who will over-estimate (‘mis-underestimate’, as GWB would say) their incomes to get a subsidy.

      Say you’re a freelancer with an income that puts you right on the subsidy/Medicaid boundary: a little less and you’re automatically enrolled in Medicaid, a little more and you get a subsidy on the exchanges. Being optimistic, like most humans, you assume that you’ll probably get at least as much work this year as last. Your optimistic estimate puts you in the subsidy category. But then reality turns out to be a real sh*t-sandwich and your actual income puts you in the Medicaid category…at which point the gov’t comes asking for their subsidy back. Now, not only are you poorer than you were expecting to be, you also owe a sizable fine to the Feds.

      GO TEAM AMERICA! WE’RE NUMBER ONE! WE’RE NUMBER ONE!…in sadistic program design…

      1. Kimberlee, Esq.

        I have serious doubts that that would happen. There are all kinds of government subsidies based on income, and if you over or under estimate your income, it’s just adjusted for the next year (or, more likely, simply based on your AGI for the previous year, and/or other information you want to supply to get them to believe this year will be different than the last).

        My income goes up each year, so my income-based repayments on my student loans do too, and they don’t ask for last years’ subsidy back just because my income was $5K more this year than on last years’ W-2.

      2. Lambert Strether Post author

        Or over-estimate their income to avoid being forced into Medicaid.

        NOTE I love the way ObamaCare ‘splainers say people are “eligible” for Medicaid; people are forced into Medicaid based on income, so the only way to avoid that is, well, to lie about what your income is.

  5. Ep3

    Yves, these “staggering” articles about obamacare have been great. I notice though they have been taking an angle from the person without insurance and their struggles. I know the law was written for those ppl specifically who are currently without (“if u have insurance thru your employer, you can keep it” BS). But I wish these articles also considered us who are getting screwed at our employers. Of course our conservative employers think that obamacare is the reason insurance rates continue to rise 12% a year. I live in Michigan. Bcbs monopolizes the market so that all that employers look at is the bottom line and they become the only option. And the threats I hear are that “we will give u a stipend and you can go on the exchange and buy insurance”. So I recently got a raise of 3%; my insurance went up 7%. And so then I will be responsible for finding a policy that is correct, and safe (who knows if I am capable of choosing a policy that covers the things I need or will need). But that again leaves me at the point of choosing health care over other expenses/savings. And my employer then has no concern or care whether I am covered or not. If I choose a cheap plan, and then get sick and go bankrupt and this causes my employment to suffer, they have no responsibility. All the fault lies at my feet. They can say I shouldn’t have been driving a new car or whatever. They were “generous” to give me an inadequate stipend (and to also not lobby for universal care). Let me point out I work for a small business with approximately $20 million a year in revenues. Not everyone is full time; in fact, the majority of employees are retail part time or warehouse seasonal.

    Anyway, medicare for all. Simple, easy, over and done. But this is the continued separation of persons in our society from the haves and the have nots.

    1. Ep3

      Yves, one other thing. In regard to the article about the savings by converting to Medicare for all, it mentions small increases in taxes. But i would gladly pay more in FICA tax if it meant I had Medicare for all insurance. Instead of me paying $355 a month to a greedy insurance company, I will send that to Medicare to cover my insurance. In fact, as the article points out, it would only take a small increase in taxes to pay for the insurance. So maybe I would only pay an extra $100 a month in taxes, while not sending $355 a month to an insurance company. A $255 a month savings. To me, the benefits far outweigh the costs.
      But of course, there will always be these Tea partiers who think that, even if they saved $1999 a month on their insurance costs, and got better coverage, they would still think they govt is screwing them somehow.

  6. steven

    ep3 I am no expert in the law but my understanding is that IF your employer plan options do not meet the silver standard and/or if you have to pay more than 9.5% out of your own pocket to buy your employer insurance (which is the lowest level subsidy for those around 400% of the poverty level on the exchanges) then you may be eligible to buy on the exchange and receive a subsidy (provided you would be eligible for a subsidy if you didn’t have employer based insurance).

    petridish said:
    “You could be in for quite a shock if you “sign up” casually, underestimate your income (to get a larger subsidy) and then get the IRS breathing down your neck to pay back the extra money you “fraudulently” accepted.”

    There is no implication that you tried to defraud the government if you end up making more than your predicted income. The prediction is going to be based on things like your previous year income. It isn’t like you are just going to randomly pull a number out of thin air. Provided you don’t try to willfully deceive the government by obviously fudging the numbers (which you probably won’t be able to do anyway as again it isn’t going to simply ask you to put any random number in as your estimated income) you aren’t going to be at risk of being accused of fraud. Just as the government isn’t persecuting people for making a mistake on their tax return the government isn’t going to persecute anyone if the estimate is not accurate.
    The irs is not going to breathe down your neck. You will simply be required to repay the excess subsidy as part of your calculated tax. I think everyone makes this sound much more onerous than it is. If you have made more money than you expected to make then you will overall be better off, even if you have to pay some additional money back for a subsidy you shouldn’t have received. The only circumstance under which I see this as possibly a problem is if you are right around the 400% cutoff and took a subsidy when you didn’t have a right to any subsidy at all. In this case there could be a number of thousands of dollars tacked onto the tax bill, which will be a reimbursement for the number of thousands a person didn’t pay in premiums. A single person has to make over 45K and a family of 4 over 95k for this to be an issue. In other words it might be a bit of a shock for such people but it isn’t going to be economically devastating. I also suspect that many of the people making this kind of money have decent employer coverage and aren’t going to be in the exchanges anyway.

    I’m not sure why you insist on holding obama responsible for the republicans refusal to expand medicaid. If the plan was being implemented as intended there wouldn’t be so many remaining uninsured. I take your point, and agree, that universal health insurance would be a better alternative. I also take your point that this system keeps the private health insurance system in place. Nevertheless most of what you say about obamacare already existed in the pre-aca world so it isn’t fair to make it sound as if the aca makes such things worse. It hasn’t solved all problems but it makes things overall better, not worse.

    1. Joe

      I wish people would stop calling thie ACA health insurance. For those that can’t afford the higher levels of service, the coverage amounts to catastrophic care only. The deductibles are high enough to discourage any use other than absolute desperation. If the care you can afford is going to bankrupt you anyway, why tithe hundreds per month to the insurance companies?

      Also Obama seems to be able to get bipartisan support when it suits him (war, bank bailouts, trade agreements, etc.). He gave up on universal coverage before negotiations even started.

      1. steven

        Lower income people will get
        1. Premium subsidies that require from 2.5% to 9.5% of yearly income to be paid out of pocket, as one goes from 100% to 400% of the fpl(which for a single person is 11000 to 45000 dollars).

        The silver plan, which is the basic standard on the exchange for everyone who isn’t very young(the very young can opt for a catastrophic type plan), will be a 70/30 plan.

        2. Maximum out of pocket for 2014 is around $6500, inclusive of deductibles/copays and coinsurance. People who make less than 250% of the fpl will also be eligible for cost sharing support to lower their out of pocket.

        I continue to be baffled by how people could suggest that it would be better for the uninsured to have remained uninsured than to become a part of this system.

        1. Joe

          I continue to be baffled that people think that those who’s incomes are low enough to qualify for subsidies, will be able to afford a monthly premium and a deductible that would be around one fourth or greater of their after tax income.

          Preventive care coverage is almost worthless. I think one physical per year would run less than $200. A years worth of premiums will add up to?

          The people promoting these plans continually show an arrogant cluelessness about what it is like to live on very limited resources. The people that will qualify for these subsidies are already making choices between eating, providing heating in the winter, being able to afford gas for their cars to get to work, etc., balanced against ever increasing costs and stagnating wages.

          1. steven

            The subsidies are available for people 100-400% of the federal poverty level. That means that individuals from around 11k to 45k and families of 4 from 24k to 94k will be eligible (assuming they don’t have good coverage under their employer and don’t have to pay beyond 9.5% of annual income, out of pocket, for premiums through their employer).

            In addition, those at up to 250% of the poverty level could qualify for out of pocket subsidies as well to help with deductibles and coinsurance and to lower their actual out of pocket maximum considerably below the $6500 mandated under the act.

            For many people though the deductibles aren’t going to be anywhere near 1/4 of their after tax income and they will be able to pay the costs they are required to pay. Of course it depends on how the deductible and coinsurance are structured to meet the actuarial requirement of 70% for the silver plan.

            For those at the lowest end of that spectrum I am not clueless about the difficulties they face. The key point, though, is this. Many of them were previously uninsured. I have yet to have someone explain to me how that situation was better for them than the situation they will find themselves in under the affordable care act. I’m under no illusions that their lives are going to be made swanky and easy as a result of this but I don’t see how people can claim that it was better to be uninsured, to have to wait until you were severely ill and then rely on emergency room care and to fact potentially limitless risk. If on the other hand they were paying for individual coverage before then the subsidies available will significantly reduce their out of pocket cost compared to what they were paying before and the new rules about out of pocket maximums will greatly reduce the risk that they face after the affordable care act vs the risk they faced before the affordable care act. So again, I assert that the vast majority of such people will be better off than they were before. Are they as well off as they would be under medicare for all universal health insurance? No. But they are better off than they were before and for people who were actually suffering this isn’t an insignificant point.
            It seems to me that it is many people who try to claim that the affordable care act makes things worse who are clueless as to the actual suffering of the poor and are willing to sustain the poor in misery as long as it furthers the agenda of pushing for universal health care. As I said before, I favor universal health insurance/medicare for all, but I am not going to try to undermine the affordable care act and keep the uninsured suffering longer because I think it will help the cause of universal health insurance. I think that is cruel and immoral.

            1. Joe

              You certainly have convinced me. I have seen the error of my cruel ways. I will immediately stop forcing people to not have insurance.

              I didn’t realize I was being such a heartless bastard.

              I pray that Dear Leader will forgive me my transgressions and foolish thought crimes.

            2. ChrisPacific

              The key point, though, is this. Many of them were previously uninsured. I have yet to have someone explain to me how that situation was better for them than the situation they will find themselves in under the affordable care act.


              Before ACA, they were uninsured because they couldn’t afford it.

              After ACA, they will still be uninsured because they can’t afford it, but now they will pay an (increasing) annual fine for their lack of insurance.

              The amount of the fine is the amount by which they’ll be worse off under ACA.

        2. Joe

          I copied this from one of the large insurer’s website:

          “Answers to Your Health Insurance Deductible Questions
          70/30 Plan

          Example: Lets say you have a $100,000 hospital bill. You will have to pay your deductible. If your deductible is $5000, you will pay the first $5000 of that $100,000 hospital bill. That leaves a balance of $95,000. Next is cost sharing of that $95,000 balance. If your coinsurance benefit on your policy is 70/30, then you will be responsible for 30% of that balance and the insurance company will pick up 70%. If your 30% responsibility is not capped, you would owe 30% of $95,000 or $28,500. However, most policies have what is called a maximum out of pocket or coinsurance limit. If your coinsurance limit is $5000, then you are only responsible for that $5000, not the whole $28,500! The insurer will pick up the difference. Therefore, your true out of pocket maximum on your policy is the deductible PLUS your coinsurance limit. In this case, you would be responsible for $10,000 (your $5000 deductible plus the coinsurance limit of $5000). Therefore, you pay your 30% until you hit that cap.”

          1. steven

            Are you sure that they claim to be talking about coverage under the affordable care act and not making generic statements about health insurance coverage pre-aca?
            The maximum out of pocket is supposed to be inclusive of deductibles/copays and coinsurance.

            1. Joe

              Do they have search engines on your planet? I consider not doing your own research lazy.

              Are you sure what I quoted isn’t correct?

              1. Lambert Strether Post author

                I’ve got to throw a flag on this. When people are challenged to back up their words with a link, they should provide it; it’s the only way we can be self-regulating in our views.

                The truth scales (and I wish I could remember which commenter said that, so I could tip my hat). We don’t have the budget to maintain a vast structure of bullshit and lies, so we have to go for the truth, but we need to be able to test for truth by checking sources. Hence the need for linky goodness.

                It’s not a matter of whether I disagree with this or that person; it’s the principle.

                NOTE Of course I can think of trollish edge cases, but those are not hard to detect. In that case, I think “Do your homework” is fine. But the bar is pretty high for that, and higher than here.

          2. steven

            I didn’t claim that your quote was incorrect. I question your interpretation in believing that this pertains to plans under the affordable care act rules. I found that paragraph at bottomlineinsurance.com

            Again, I see nothing that mentions the affordable care act. What is being described there is the way that things work at the moment. Under the affordable care act there is a much simpler and exacting definition of out of pocket maximum. Insurance companies aren’t able to play as many games as they used to be able to with the definition of what is and isn’t included in the out of pocket maximum. The out of pocket maximum is inclusive of deductibles and coinsurance. I don’t think what is being described in that paragraph is any longer an acceptable definition of out of pocket maximum for exchange plans that meet the affordable care act requirements.

            1. Joe

              If it isn’t obvious to you let me make it clear to you that I have no interest in what you “think”. Provide a link or or provide a quote that backs up what you are saying. I’m not here to prove your point for you, that’s your function.

              You seem to be taking this discussion so personally that the only conclusion that I can draw is that you either work for the Obummer administration or an insurance company. Care to share which?

              You and the other concern trolls do provide me quite a bit of entertainment though. Thanks for the lulz and have a good night.

              1. steven

                Why does your every word have to drip with such contempt?

                Why am I not allowed to feel as strongly about this subject as others here?

                And no, I don’t work for obama or any political group, nor any health group, nor any insurance company. I simply care about this subject and am trying to provide substantive and accurate information.

                Here are a few links in support of what I am saying:



        3. Lambert Strether Post author

          I’m suggesting that ObamaCare doesn’t include everybody and doesn’t treat those it does include equally.

          So, you may indeed by “baffled,” but not by the central claim of the post, which you do not address.

          1. steven

            “I’m suggesting that ObamaCare doesn’t include everybody and doesn’t treat those it does include equally.”

            I can’t disagree with this. What you say here is true.

            The question is, where do we go from here? The aca is the law of the land. Single payer universal health insurance isn’t. Do you believe that the affordable care act should be abolished?
            If you had to choose between the affordable care act or the way things were before do you believe that it would be better to return to the way things were?

            1. Lambert Strether Post author

              I reject the choice. ObamaCare should be replaced with a plan that treats people fairly and provides universal coverage; single payer would do that. I also think that ObamaCare will end up benefiting some people, as I keep saying, so I think it would be wrong to get rid of it (and the Republicans are just stupid and out of control to keep trying to do that (tax resistance to the mandate would not only be smarter, it would be in accordance to their traditions as a party)).

              What I vehemently reject is the smug position that because some are helped, it’s OK that all are not. How would you feel if you were put “in the back of the bus”? Or under it?

              1. steven

                “so I think it would be wrong to get rid of it”

                Thank you for replying to my question. I misunderstood and didn’t think this was your position.

                To clarify my own position I don’t believe it is ok that others aren’t helped. I just believe you do what you can with what you have to work with and if you can alleviate suffering somewhere you do so, as long as it isn’t imposing significant additional suffering on others, even though you may not be alleviating all suffering. I don’t think the affordable care act is the final word on all of this in america.

      2. Kimberlee, Esq.

        What you say is incorrect. All exchange insurance plans (and, I believe, all insurance plans in general) are required to provide no cost, no-copay and no-deductible preventative medicine. As in annual physicals, annual well-woman, etc. There is no plan on the exchanges that amounts to “catastrophic-only.” They also all have out-of-pocket annual maximums, which can be high in some cases (I think the highest one, in the law, is something like $7K, which is still a lot of scratch to come up with), but people being bankrupted by medical bills despite having insurance will likely be much less common as a result.

        1. Lambert Strether Post author

          Oddly, or not, you omit to mention that the out-of-pocket limits were delayed. As for decreasing bankruptcies, the numbers from RomneyCare are at least disputed; a person can drown in a puddle of water just as well as in the ocean (as you point out, $7K is a chunk of change), and there is also income loss from being out of work to consider. The preventative stuff is nice-to-have, I agree, but really, bandaid on cancer-level stuff.

          Finally, I agree that ObamaCare will help some; however, it will not help all, and will not help all equally. The easy willingness of ObamaCare apologists to throw millions of people under the bus has, alas, no longer ceased to amaze me.

        2. Alexa

          It sounds like a couple of bloggers here haven’t famiilarized themselves with the new category of health care insurance plans that ObamaCare has spawned: “Skinny Plans.”

          Here’s an excerpt and a link, below.

          Obamacare penalties spawn ‘skinny’ plans

          Employers heaved a sigh of relief when the Obama administration announced it would not enforce Obamacare’s mandate that large companies provide insurance to their workers next year.

          But some companies plan to offer “skinny plans” designed to duck the biggest penalties anyway, according to industry consultants.

          And the Obama administration has extended its blessing to this limited coverage, even though it would not protect individuals from medical bills that could cause financial ruin in the case of severe injury or illness.

          The health law spells out in detail the comprehensive coverage that insurers have to provide on the new insurance marketplaces or exchanges.

          But it’s nearly silent about what the employers who provide insurance to a majority of Americans need to include in their health plans. . . .


          The ACA is a travesty. It was intended to “benefit” the relatively affluent and governments–especially state and local–AND IT DOES JUST THAT.

          Just wait until all the working and middle class Americans who have their (one time half-way decent) “group health insurance plans” eviscerated, get finished with the Democratic Party at the polls.

          Oh, and the millions or low-income Americans who were “promised” health care through Medicaid, who won’t be eligible now.

          And please, don’t waste your time defending the Administration by blaming those dastardly Republican Governors.

          Only the most naive of folks would have believed that Republicans would embrace the ACA. I mean, please–get real.

          The law SHOULD HAVE (if not established MFA) included the lowest-income Americans in the Health Exchanges with the rest of the American population. These plans should have been subsidized 100%, with perhaps a very low annual deductible–which would have been considered the beneficiaries’ contribution.

          Talk about blatant “class” discrimination, for cryin’ out loud!

          Heck, there are very few doctors in my University town that even accept NEW Medicare patients–much less new Medicaid patients!!!

          The only way that Democrats can possibly rectify this looming fiasco is to drop the “individual mandate” to buy defective private market health insurance, and replace it with Medicare-For-All, and I mean a heavily subsidized MFA–not the one that the Democratic Party Senators were touting for seniors age 55 and over–you know–a “buy in” with NO federal subsidies).

          Actually, it’s probably too late.

          Very few people that I know trust the Democratic Party on healthcare policy, anymore.

          IMHO, the only hope for MFA will probably be a third party candidate.

          Heck, if the kickoff and implementation goes anywhere as bad as Lambert’s writing would indicate, Republicans might even win in a landslide.

          Hopefully, though, a real left-wing candidate will take the opportunity to fill the “vacuum” that corporatist Dems and Repubs have left, and make a serious run for the White House in 2016.

          [Sort of pushed for time this p.m. Apologize in advance for typos/bad syntax, etc., ;-)]

    2. diptherio

      Not the Democrats (and Obama’s) fault for announcing immediately that single-payer was “off the table”? IIRC, Obama entered office with a mandate for single-payer (having campaigned on it) and then dropped it like a piece of hot poo once he got elected. Am I remembering things incorrectly?

      1. steven

        Your memory is correct that obama did not put forward or make a case for single payer. This is a legitimate criticism of him.
        Does this mean, though, that he is now responsible for everything that happens from that moment forward? How does that make him responsible for conservatives taking the law to court and having the medicaid expansion requirement struck down and then refusing to expand medicaid to try to subvert the law?
        Do you think if we had single payer that the conservatives would be less aggressive in their attempts to subvert the law? How is this the president’s fault?

        1. diptherio

          Um…Obama did say that he supported single-payer while he was campaigning. Click the link in my comment above for proof.

          Thanks for playing, though…

          1. Lambert Strether Post author

            I yield to no-one in my lack of willingness to make apologies on Obama’s behalf, but in this case (see below) I don’t believe that you’re right; I don’t think that video is form the 2008 campaign.

        2. Lambert Strether Post author

          Ever hear of Harry Truman? “The buck stops here.” I get so tired of Obama apologists pushing this twaddle, especially after handing us all that line about Obama being a “transformative” President& (and then shifting, on a dime, to “Presidenting is hard”). In 2009, Obama — then universally hailed as extremely disciplined politically and as the greatest orator of his generation — and the Democrats controlled the House, the Senate, the Presidency, and had been elected with an overwhelming mandate for “hope and change.” The Republicans were completely discredited. Obama, as party leader and using his mandate, could have gotten Medicare for All passed with a simple majority, either through the reconciliation process or by changing the Senate rules at session start to abolish the filibuster. He did none of that, and therefore — whether as party leader, President, or the holder of mandate — is thoroughly responsible for the outcomes.

          NOTE * To be fair, Obama has been transformative. I just didn’t expect him to transform into the third Bush administration.

      2. Lambert Strether Post author

        I don’t think that video comes from the 2008 campaign, although Obama did verbally support single payer in 2003, he was already backing off by 2006.

        In the 2008 campaign, Obama ran “Harry & Louise”-style ads attacking Clinton for supporting the individual mandate*, which Krugman called him out on.

        Once elected, Obama and his administration dissed single payer at every opportunity, including mocking its advocates, censoring Town Hall coverage, and cancelling his own family doctor’s appearance at a forum, since he was going to advocate single payer.

        Kathleen Sebelius says Obama’s goal is to block single payer permanently.

        So when you hear ObamaCare apologists, Obama operatives, and career “progressives” say they want ObamaCare to evolve in the direction of single payer (or even universal coverage), take that with a mountain of salt. Based on their track record, they’re lying.

        NOTE * If you accept the premise that people should be forced to buy a defective product (health insurance) then the mandate is the only way to achieve universal coverage (which, as I show, ObamaCare does not do, despite Clinton’s weasel wording).

    3. sd

      Obama has control of the bully pulpit. Not once did he use that pulpit to educate the American public that Medicare for All was an option.

  7. middle seaman

    Criticism of Obamacare is as old as Obamacare. It was never an honest attempt to provide close to universal health care. Rehashing the plan or its implementations leaves very little extra value.

    Clinton, the rescuer in chief, joins the selling effort not as an analytical observer. Without Clinton’s attempts at health care reform and his attempts to integrate gays into the military, we will still be living in Alabama.

    Now focus should fall on where health care goes from Obamacare. Can we turn it into universal health care, how well does it work and what has to be done improve health care.

    1. Kimberlee, Esq.

      I agree, I’m really interested to see how this changes healthcare. For one, the exchanges really will be game-changing.

      The author is slightly wrong about not being able to compare plans like TVs; while it’s true that each plan will be different, they all have to provide a minimum level of coverage. The basics will all be the same; the things that will be different between the plans now is stuff like the deductibles, the co-pay, and the co-insurance. The meat of the plans, what is actually covered, will be largely to entirely identical. So being able to look at a chart and see what the same type of plan costs across 3 different providers will definitely change the way people shop for healthcare.

      1. Lambert Strether Post author

        Please reread the post. What the cited Kaiser study shows is that coverage will vary in practice by the plan, no matter what the simple bullet points on the Exchange website say. Those variation are, of course, not visible on the Exchanges at all. Hence, the plans are incommensurate. “The same type of plan” is somewhere on the border of meaningless and outright deceptive.

    2. Lambert Strether Post author

      I disagree. “Repeat, repeat, repeat” is the only way to put an idea across (and I hope I do the repetition with sufficient variety and panache to keep the subject matter fresh for most readers).

      The comment immediately below proves my point. The Exchanges are in no way “game changing.” In fact, the Exchanges are the same old game — possibly with snappier referee uniforms and instant replay — of rental extraction to the tune of $500 billion a year. ObamaCare (and its apologists) normalize that game.

  8. km4

    “If we’d passed single payer Medicare for All in 2010, we would already have saved a trillion dollars and a lot of grief.”


  9. anon y'mouse

    if Oregon installs their own health plan, I shudder to think of what it might be like. they already have their own worker’s compensation insurance company, and you’re captive to that if anything bad happens to you. there’s a list of doctors who basically understand that to continue receiving patients, they need to make sure that nothing costly gets done.

    also, there don’t seem to be any public hospitals in this state (that I’ve found). they are nearly all religious-based or owned companies. how do you run a public health system with no public hospital?

  10. petridish

    Meahwhile, back on capitol hill:

    On This Week with George Stephanopoulos, comes the Sunday Spotlight. (No link up yet)

    Today’s story is about Jaime Herrera Beutler, Republican, Washington.

    Apparently Ms. Beutler recently gave birth to a daughter, three months premature. During a routine prenatal ultrasound, the parents were informed that no kidneys were present in the fetus. The diagnosis was Potter’s Syndrome, a rare birth defect in which lungs and kidneys fail to form due to a lack of amniotic fluid. The prospective parents were told that this condition was incompatible with life. The prospective parents were offered the opportunity to terminate the pregnancy which they declined.

    The Congresswoman and her husband sought experimental treatment at Johns Hopkins where saline injections were performed as a substitute for amniotic fluid. When Abigail Rose was born prematurely, she had lungs “able to sustain life” but no kidneys.

    The child will spend the next six months at Stanford Children’s Hospital. She will require daily dialysis until she receives a kidney transplant. “Miracle” is the word repeatedly used.

    According to the piece, the “multi-million dollar” healthcare costs will be paid by MEDICARE (yes, that’s what they said) and the congressional healthcare plan.

    More on Ms. Herrera Beutler and healthcare reform for those NOT in Congress:


  11. craazyboy

    October is shaping up to be a busy month. Obamacare debuts, then the House has been making noises about delaying the Syria vote a week, so Syria likely on the October calendar too. Then Jack Lew has been raiding the federal pension fund to pay bills for as long as he can and looks like October is it for the budget ceiling. Then Halloween on the 31st.

    Hardly seems like there will be any time for NFL football on Sunday???

    1. petridish

      Don’t know about that. Word on the street was that the earliest Obama could address the grave, planetary threat of chemical weapons in Syria was Tuesday–because football had already claimed Sunday and Monday.

      Priorities, you know.

  12. myshkin

    “Have I ever explained? No; there are many advocacy groups, like PNHP, that can do a better job of that than I could. What I can do, and I hope, am doing, is raising awareness, which is the first step to making any change anyhow.”

    Fair enough and indeed you have raised my awareness on the issue. PNHP is promoting H.R. 676, Medicare-for-all bill. How that might become law in todays congress, or any forseeable congress underwritten by corporate America can only be envisioned in a pipe dream.

    That many of the state legislatures are as throughly corrupt or more so than congress suggests the state by state model faces overwhelming obstacles.

    However universal bills in Vermont and to a lesser degree California (passed twice and vetoed by the governor) and perhaps Oregon and the experience of Canada indicates the likely road to universal will be state by state and that the silver bullet bill coming out of Congress isn’t likely unless there is a massive shift.

    “If, every time a consumer citizen has a rotten experience on the Exchanges — and there will be million of them — and they think “There has to be a better way,” that will be the foundation of everything.”

    They may think “There has to be a better way,” unfortunately many of them will be swayed by the preponderance of propaganda pushing the insurance industry solution, yet some citizen Sisyphus will probably start rolling the rock back up the congressional hill.

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