ObamaCare Staggers Toward the October 1 Finish Line (6)

By Lambert Strether of Corrente.

And never mind that the Democratic nomenhackura has redefined October 1 as a “soft launch”; it’s still the first chance people are going to get to see the Exchanges in action, and you never get a second chance to make a first impression. And never mind the whole defund ObamaCare slash government shutdown slash debt ceiling mishegoss and all the yammering and posturing and hostage-taking and fundraising appeals [whines] because they really need the money; after all, the Republicans looked crazy when Newt shut down the government and then impeached Clinton over a *******, and they went on to win the next two Presidential elections, at least for some definition of win, so really, who knows and who’s crazy?

Be that as it may, tonight I want to first look briefly at a modest proposal by Paul Krugman in his blog, “The Conscience of a Liberal“; then at the open bullshit purveyed by all parties in the ObamaCare debate and, more importantly, at the unspoken agreement between them; and finally I want to take note of a few orts and scraps I found along the way.

Here’s an extract from Krugman’s September 21 blog post, I Have Seen The Future, And It Is Medicaid:

I Have Seen The Future, And It Is Medicaid

… We have ample evidence that we do know how to control health costs. Every other advanced country does it better than we do — and Medicaid does it far better than private insurance, and better than Medicare too. It does it by being willing to say no, which lets it extract lower prices and refuse some low-payoff medical procedures.

Ah, but you say, Medicaid patients have trouble finding doctors who’ll take them. Yes, sometimes, although it’s a greatly exaggerated issue. Also, middle-class patients would surely be unhappy if transferred from the open-handedness of Medicare to the penny-pinching of Medicaid.

…. So, I’m not proposing that we turn the whole system into Medicaid any time soon. But what I take from the data is that if and when we feel the need to make tough choices — really, really make tough choices, not use the rhetoric of tough choices to justify what conservatives wanted to do in any case, namely privatize everything in sight — health cost control won’t turn out to be that hard after all.

“Any time soon“? Alrighty then.

While I’m sure there will be some readers who would take issue with “the open handedness” of Medicare, I want to focus on additional “ample evidence” not presented in Krugman’s post. Krugman knows about it, because it comes from an article he wrote:


And Krugman writes:

American Medicare is expensive compared to, say, Canadian Medicare (yes, that’s what they call their system) or the French health care system (which is complicated, but largely single-payer in its essentials); that’s because American-style Medicare is very open-ended, reluctant to say no to paying for medically dubious procedures, and also fails to make use of its pricing power over drugs and other items. So Medicare will have to start saying no; it will have to provide incentives to move away from fee-for-service, and so on and so forth. But such changes would not mean a fundamental change in the way Medicare works.Now, Canadian health care isn’t perfect — but it’s not bad, and Canadians are happier with their system than we are with ours in the United States. So anyone who tells you that Medicare as we know it — a single-payer system that covers everyone over a certain age — is unsustainable is ignoring the clear evidence that other countries somehow manage to make similar systems quite sustainable.

So it’s evident from Krugman’s own work that we can (a) have a single payer* system in the United States that would (b) save a boatload of money, (c) “say no”, and yet (d) still be “open-handed”, as David Himmelfarb notes:

A single payer system is better for patients and better for doctors. Canada spends $1000 less per capita on health care than the U.S., but delivers more care and greater choice for patients.

Canadians patients have an unrestricted choice of doctors and hospitals, and Canadian doctors have a wider choice of practice options than U.S. physicians.

Canadians get more doctor visits and procedures, more hospital days, and even more bone marrow, liver and lung transplants than Americans.

Here’s what Krugman’s first commenter says on the Medicaid model:

Have you noticed all the poor and homeless with missing teeth? (You will now that I’ve mentioned it.) That’s because in order to “control costs” in 2009, Medicaid (Medi-Cal here in CA) simply eliminated dental services for adults. Don’t worry though – they still pay for the teeth to be pulled before these people die of infection (generally).

(Note that in the United States, bad teeth are a class marker, so it’s harder to get a job with bad teeth, no matter your skills.)

So why on earth is Krugman advocating the Medicaid model, as opposed to the Medicare model, given that both can “say no”? (Never mind that under Medicaid, after 55, you pay for your care with your assets instead of passing them on to your kids; and never mind that a lot of Medicaid services are contracted out to private entities, which Krugman seems to think that only Republican practice; how droll.) I can’t imagine why; hating on the poors wasn’t my picture of Krugman’s worldview. Still, it has to be said that if you want to look for a Medicaid program that really got gutted, look at how Democratic governor Phil Bredesen (founder of HealthAmerica Corp.) “said no” with TennCare (hat tip Alexa), which I suppose could turn out to be a blueprint for “the future”:

(It’s quite a long video, but if you listen to it with your morning coffee you’ll hear a story of Democratic duplicity and treachery that rivals any story that can be told of Republicans.) Here’s the money quote from Democratic Governor Bredesen [13:53]:

[BREDESEN:] Well, um, I certainly don’t want anyone and don’t blame anyone who’s going to die as a result of any of this.

BWA-HA-HA-HA-HA! Except not. Why does Krugman want to climb into bed with this guy? Why go for a Medicaid model and not a Medicare model, especially when the Medicare model meets your expressed requirements? And poor people don’t end up with rotting teeth? ‘Tis a puzzlement!**

* * *

Let’s move on to the epic celebrity death cage match now taking place on Capitol Hill over ObamaCare. I wanted to find out what both legacy parties had to say, so I looked up Ted Cruz (on Limbaugh; his quasi-filibuster transcript wasn’t available), and I also looked at the comfy, Oprah-like conversation that Obama and his gracious host, Bill Clinton, shared with us at the Clinton Global Initiative (“I think President Clinton makes a really important point”). And — I know this will come as a shock to you — everything they had to say was bullshit. There’s so much bullshit I can’t hope to cope with it all, so I’ll just point out some of the more grotesque examples, starting with Cruz. (Cruz is a lot punchier than Clinton or Obama, and Limbaugh feeds him his lines effortlessly.)

Cruz on Limbaugh, 2013-08-28:

[CRUZ:] Look, Rush, Obamacare, as you know, is the biggest job killer in the country, and the wheels are falling off of this thing.

Well, we keep hearing anecdotes, the most recent being UPS; and for sure the university administrators are abusing their adjuncts brutally. But for the “job killer” claim to be true, we’d have to see the figures show up in the disemployment reports somehow; Hugh’s been monitoring them, and we don’t see that.

[CRUZ:] [ObamaCare’s] intent is to destroy the private insurance business, to cause people to lose their private health insurance and be forced, essentially, to move to single-payer, government-provided health insurance, which was Nancy Pelosi and Barack Obama’s plan from day one.

Except ObamaCare was RomneyCare was HeritageCare, originally devised with the exact purpose of heading off the dreaded single payer. Further, ObamaCare was crafted by Liz Fowler, a Wellpoint VP on secondment to Max Baucus as his CoS, so we’d have to believe that an insurance VP set out to destroy their own industry. Finally, if the Democrats really had single payer in mind, the White House would hardly have mocked and censored single payer advocates.

[CRUZ:] On January 1st, the subsidies are scheduled to kick in, and President Obama’s strategy is very simple. He wants to get as many Americans as possible addicted to the subsidies, addicted to the sugar, because he knows that in modern times, no major entitlement has ever been implemented and then unwound.

Well, those disenrolled from TennCare — granted, by a Democrat — might disagree. And ZOMG!!! Subsidies?! Shocked, shocked. (I myself would have framed this differently: I would have said that Obama wants to give as much walking around money as possible to his campaign apparatus, in the form of grants for Navigators, administrators, PR people, web site builders, trainers, and so forth, and get them “addicted” to their cut from the rental stream.)

Bill Clinton at the Clinton Global Inititiative, 2013-09-24. He’s so charming you’d almost believe him, if you didn’t know him:

[CLINTON:] I’ll give the President a chance to talk about all the good stuff that’s happened, but I just want you to know one thing. In the last three years, just as we started doing this, inflation in health care costs has dropped to 4 percent for three years in a row for the first time in 50 years. Fifty years. (Applause.) Before that, the costs were going up at three times the rate of inflation for a decade.

Wowsers. “Just as we started doing this” is — give credit — a spectacularly bold example of using the post hoc fallacy while saying outright that you’re using it! Clinton, that lovable scamp. But wait! Could there have been anything else going on in that same time frame that would account for lowered health care spending? Something like the worst economy since the great Depression in the 30s? Why yes:

Actuaries at the Centers for Medicare and Medicaid Services, who don’t answer to the White House, said yesterday in the journal Health Affairs that costs eased because of the economy, not Obamacare. … The report also contradicts independent economists who had attributed spending reductions more to the Affordable Care Act and changes in the health system, such as shifts in employer benefits. The CMS actuaries, who track medical spending by the government, individuals and insurers, examined 50 years of data and found no evidence of costs deviating much from the economy.

Back to the Explainer-in-Chief:

[CLINTON:] But I will close with a story. I told you all this morning that the employee that our health access program lost in the Kenya mall shooting was a Dutch nurse. And we spend a lot of time in the Netherlands; we get a lot of support there. Oxi is one of the biggest insurance companies in Europe. They’re one of our partners here. I went to celebrate their 200th anniversary with them. They started as a fire insurance company with 39 farmers, 200 years ago.

He is so good. Think about it. The man can domesticate an insurance company.

And we were out there in this big farm field in a tent in the shadow of a 13th century church and a big Dutch windmill. And I asked the chairman of the company, I said, do you write health insurance? Because in the Netherlands there’s no Medicare and no Medicaid, everybody is on an individual mandate and you just subsidize people based on their incomes.

Here’s a little information on the Netherlands the Big Dog left out (granted, from 2008):

Bottom line: The most important point for single payer advocates is that every country with universal coverage has a non-profit insurance system. …. Sickness or social insurance funds do not operate like insurance companies in the U.S.; they don’t market, cherry pick, set premiums or rates paid to providers, determine benefits, earn profits or have investors, etc. In most countries, sickness funds pay physicians and hospitals uniform rates that are negotiated annually (also known as an “all-payer” system). ** Many countries are tinkering with how sickness funds operate (e.g. Germany). The most extreme change is in the Netherlands, which since 2006 has allowed the non-profit regional sickness funds to become for-profit insurance companies, and new insurance companies to form, in the hope that “competition” would control costs. After just one year of experience, the country has experienced 1) a wave of anti-competitive mergers of the insurers 2) emergence of health plans that “cherry pick” the young and healthy and 3) loss of universal coverage and the emergence of 250,000 residents who are uninsured and 4) another 250,000 residents who are behind on their insurance payments. All of the positive data from the Netherlands (on costs, infant mortality, quality, etc) is based on the system pre-2006 (personal communication, Hans Maarse).

So, Clinton can have universal coverage, or he can have heartwarming stories of windmills and churches, but he can’t have both. Back to Clinton’s story:

[CLINTON:] He said, yes, I write it; we all do. And he looked at me and he said, but we don’t make any money on it. And he said, we shouldn’t. This guy is running a huge — can you imagine somebody saying that in America? (Laughter.) He said, we shouldn’t. If I can’t make money on this business doing traditional insurance business, I’ve got no business in the work. He said, look, health care is a public good and you’ve got to find a way to finance it for everybody. (Applause.) And he said, it’s just an intermediary function that somebody has to handle. But in the end, it’s how it’s delivered, how it’s priced, and how healthy you can keep your people.

So, why do we need insurance companies in the equation at all, then, Bill? Aside from getting “a lot of support,” that is.

And finally Obama at the CGI, 2013-09-24:

[OBAMA:] People generally don’t like to be told you’ve to get health insurance. And employers don’t like to be told you’ve got to give your employees health insurance. But as a society what we cannot do is to say you have no responsibilities whatsoever but you’ve got guaranteed coverage.

A classic false dichotomy, since employer insurance vs. mandated private insurance are not the only options. People have responsibility to pay taxes, too, and those taxes could fund a single payer system; that’s certainly possible in Canada.

[OBAMA:] I can tell you right now that in many states across the country, if you’re say a 27-year-old young woman, don’t have health insurance, you get on that exchange, you’re going to be able to purchase high quality health insurance for less than the cost of your cellphone bill.

First, oddly, or not, Obama’s also making the same claim, except for families, not individuals:

So just think about that. Knowing you can offer your family the security of health care –- that’s priceless. And now you can do it for less than your cell phone bill. That’s what change looks like.

Second, neither claim is true. The average individual’s phone bill is $71 a month. According to the White House’s own doubtless self-serving figures, released today, “a 27-year-old with income of $25,000 will be able to get [silver] coverage [including subsidy] for $145 a month.” So Obama’s only off by 100% for young women. It’s even worse for families: The average family spends $139 a month on cell phones. Again according to White House figures, “a family of four with income of $50,000 will generally be able to buy a silver-level plan for $282 a month [including subsidies].” So Obama should really stop lying about this. Discrepancies like these actually matter to people who don’t have a lot of money.

* * *

Next, I’d like to talk about the unspoken agreement between both parties and the entire political class. Some of you may remember that there is an actual, principled argument against ObamaCare: People shouldn’t be forced to enter markets.

Government could mandate Americans to make deposits in or buy bonds or shares issued by financial institutions like Citibank or Goldman Sachs if, because of the next financial crisis, they don’t seem to have enough money. So, there’s plenty of experience to suggest that if the Obamacare mandate is upheld, we could find ourselves entering a strange new world where the word “contract” — traditionally meaning mutual agreement – comes to signify all sorts of things people don’t want to do.

Now, from where I sit, my first concern isn’t being forced to buy shares in anything. But I can see no reason at all why the ObamaCare “Exchange” model wouldn’t be rolled out to everything. Why not, after all, force people to buy “retirement insurance” on retirement “Exchanges,” where Social Security becomes “the public option,” and then is gradually starved? Why not force people to buy “intellectual property insurance,” in case they inadvertently violate some licensing agreement? Why not force people to buy Lottery tickets, Shirley Jackson style? I’ve tried to think of a sticking point, a swale on the slippery slope, and I haven’t been able to. (Needless to say, forcing people into a marketplace is abhorrent to both right and left so, strange bedfellows.)

However, and importantly, Cruz doesn’t make the critique, and so far as I know, no other Republicans do either. That means that both legacy parties share the most critical principal behind ObamaCare, which is that its OK to force people to enter a market. That makes ObamaCare perhaps the first open “market state” program, with market state defined as follows:

The role of the state is to determine which provider shall collect rents for delivering a service to consumers.***

It seems to me that’s what ObamaCare does — it structures the market, determines who collects the rents by entering it, and guarantees a rental stream by mandating consumers to purchase within that market — and therefore we can expect more programs like it if our transition from nation-state to market-state continues. Note that Krugman’s conversion from Medicare to Medicaid advocacy fits well with a market state approach, since so much of Medicaid is contracted out, and it’s now starting to be outright privatized. We should watch the terms of the Grand Bargain carefully to see if more market state programs emerge. In our brave new world, Bloomberg wouldn’t be stopping people from buying soda, he’d be forcing them to buy healthy bottled water!

* * *

Finally, a few random orts and scraps. First, ObamaCare’s timing is and has always been driven by electoral politics. Somebody let the cat out of the bag to WaPo:

Democrats point out that Obamacare’s implementation schedule wasn’t an accident. It was purposefully designed to begin in an off-year. That way there would be a year to work out the worst kinks, and by the time of the actual election, Democrats could point to millions of people getting insurance, running ad after ad highlighting constituents who now have coverage. If implementation didn’t begin until October 2014, all voters would know about Obamacare would be the early glitches, as insurance coverage wouldn’t begin until January 1, 2015.

Leave aside the utter cynicism of taking four years to implement a program that leaves half the target population uncovered, all for a bump at the polls. Which party really is the lesser evil, here? And as long as we’re talking about the election cycle, LBJ rolled out Medicare in one year, back when Don Draper roamed the earth, and if the Democrats had abolished the filibuster in 2009 and socked it to the Republicans, they could have rolled out Medicare for All in 2010, and had two years of covering the entire country to run on in 2012. So why didn’t they do that?

Second, how many single payer advocates are there, really? Heaven forfend that our famously free press should actually poll on this point, but we do have a proxy:

In the latest CNN poll, 54% of respondents opposed Obamacare, but of that group, 16% opposed it because they thought the bill was not liberal enough. There is a core group of progressives who do not like the bill because they feel it did not go far enough, which is, to a degree, hurting the president’s cause.

And it’s hard to see what “not liberal enough” translates into except Medicare for All (despite the “progressives” having polluted the discourse with “the public option” while running interference for ObamaCare). This contrasts to the approximately 22% of the population who are strong Tea Party supporters. So the strength of single payer on the ground is not neglible.

NOTE * Oddly — Times style guide issues? — Krugman doesn’t actually use the phrase “single payer” in his post.

NOTE ** I suppose the flip side of the “tough choices” — which never seem to involve tough consequences for the elite, oddly enough — is some sort of fiscal disaster or collapse so gross that it can’t be remedied by mothballing a few carrier groups or grabbing what the squillionaires have stashed away overseas, and other pleasant hitherto unconsidered policy options. But if that’s Krugman’s argument, he should make it.

NOTE *** As opposed to providing services for its citizens.

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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. tongorad

    Great writing, as usual, about the Obamacare ripoff.
    Hard to read those Clinton quotes without vomiting, however.

    1. craazyboy

      I wonder if Clinton got his usual $200K speaking fee for those, or if he gave it to us “pro bono”, as it were.

      But I still have this image in my mind of “goin’ dutch”, windmills, farmers, insurance companies and demobamacare. Kinda like awarding the Nobel Peace Prize in advance. It all works, just not implemented yet.

    2. anon y'mouse

      the biiig swindle is on when they pull Uncle Billllll out of the cellar and hand him a microphone.

      Uncle Billlll is much like those British/Aussie guys they use to pull the really big swindles on late night infomercials. you know it’s crap when they try to sell it to you with an accent.

    3. sgt_doom

      Ditto your comments — this is simply a most brilliant blog posting!

      “non-profit insurance system” states the entire case — having done untold number of hours of volunteer political activism on the financial side, a major tangetial benefit of researching hedge funds and private equity/leveraged buyouts was observing the data on its effects on the rising costs of health insurance from 2000 to 2009 — from hedge fund speculation across the entire healthcare sector, and private equity LBOs across the entire healthcare sector!

      If we had a non-profit as opposed to private health insurance structure, things would be entirely different!

  2. petridish

    At this point, I personally do not care what kind of a whack-job Ted Cruz is or who feeds him his lines. This is not a messenger I want to kill–he’s got the right message.

    As I see it, the only way to fight narcissistic sociopaths like Clinton and Obama is with narcissistic sociopaths like Ted Cruz.

    Try reading the Bloomberg article in today’s Links section about deaths caused by the overuse of stents. The stupefyingly craven US “healthcare” system that Obamacare is intended to maintain is just begging to be blown up. I don’t really care who lights the fuse, just get on with it already.

    1. Doug Terpstra

      Agreed. It would be great to pronounce ObamneyCare DOA.

      Too bad it’s pure theater. What we are witnessing is the usual frontal assault by Republicans in concert with typical deceit and treachery by Dixiecrats. Both work for the narco-insurance rackets of course and both really need this monster bailout, so we can cry all the way to JPMorgan.

      That’s because there is still one “slim” chance ObamneyCare could still be “saved”, and that is … wait for it … if we could “save” Social Security in the process. If only the ever-so-reluctant, “I will not compromise” premature capitulator could be somehow persuaded to commit the Grand Betrayal, then this terrifying cliffhanger might, just might, be resolved.

    2. jrs

      Other than a few public health benefits like antibiotics (the ones that still work), immunizations, and basic sanitation, none of them small things, it will eventually reach the point where noone in the U.S. has healthcare anyway even if they have insurance, if it hasn’t already. And I guess we’ll just accept a pre-healthcare lifestyle. It seems the only one likely to come about anyway. There will be no such thing as healthcare in this country.

    3. hunkerdown

      The question is, who’s got the kill switch on the psychopaths? Remember, the employee has more rights to wreck up the place and get paid every penny until they clock out for the end of their shift than the employers/constitutents have to stop the damage.

  3. TimR

    Lambert, responding to Cruz you write (paraphrasing) “ZOMG! Subsidies? I would have framed this differently…”

    But to clarify – Most people will experience Obamacare as a “tax,” with “subsidies” just slightly defraying that, right?

    I live in a red state, and even listen to Limbaugh et al sometimes, and this has been one of the head-spinning things to me – that conservatives somehow view this as just another Big Government program from that Librul (secret Socialist) Obama… And when I confront them with its anti-free market mandate to buy a product in the marketplace, they say “Sure, but that’s just a ploy, it’s designed to self-destruct, wipe out the insurance companies, and we’ll end up with single payer.”

    (Although way back when this was going to the Supreme Court, I seem to remember there were a lot of people, Limbaugh included, who were disturbed by the violation of market principles in forcing people to contract with private companies. After the ruling they seem to have accepted this, or at least buried the issue out of mind.)

    It’s strange to me that Cruz and conservatives are so rabidly loathe to “subsidize” the Malingerers, the good-for-nothings, and the lazy, that they distort the real issue: shouldn’t they be appealing to their No New Taxes philosophy, and casting Obamacare as a giant Tax Increase? (Albeit a tax paid to private companies.)

    1. craazyboy

      What tax increase? There is no tax increase, same as no tax funding for Bush’s Medicare Part D. It’s “funded” by the deficit. That’s the beauty of it. It gives our insanely overpriced healthcare system, plus private insurers, a direct line to treasury borrowing. Status Quo preserved, once again.

      Not to say taxes won’t have to be increased someday. In that case, kids born today will be paying for their own hospital birth bill. Rush would like that, I think.

      1. diptherio

        Anyone who can’t afford insurance (or just chooses not to) will be taxed by the IRS for their failure to comply…that’s a pretty immediate increase for some of us.

        1. craazyboy

          I was referring to the subsidy you get – billed to the Treasury. 100% at very low income, then is on a sliding taper all the way up to $80K family income.

          The IRS “fine” is for if you don’t accept the subsidy, or make more than $80K and refuse to buy insurance.

      2. TimR

        I put “tax” in quotes, what I mean is that *in effect* it’s a tax on the individual, who must now devote a percent of their income to health insurance, regardless of how the math works out for them, or what they think of the “product.”

        It won’t just be the govt subsidizing the insurance companies, it will be the new mandatory customers, who must buy their product regardless of quality.

        In my case, I may qualify for Medicaid, but my income varies, so I may also be forced to buy some low quality plan, and I’d rather not.

        1. craazyboy

          I usually describe it as having a crappy over priced “product” crammed down my throat.

          Then we’ll have to listen to how SS & Medicare need to be cut, even more so now as this hand out to the healthcare industry increases the deficit.

          George Carlin did say they will get our SS.

    2. diptherio

      And when I confront them with its anti-free market mandate to buy a product in the marketplace, they say “Sure, but that’s just a ploy, it’s designed to self-destruct, wipe out the insurance companies, and we’ll end up with single payer.”

      So there are Republicans who buy into the whole “11-dimensional chess” school of thought as well, eh? Too funny…

        1. TimR

          It’s right there in your article in the Cruz quote, no?:

          [CRUZ:] [ObamaCare’s] intent is to destroy the private insurance business, to cause people to lose their private health insurance and be forced, essentially, to move to single-payer, government-provided health insurance, which was Nancy Pelosi and Barack Obama’s plan from day one.


          But yes, I know somebody who subscribes to Austrian school economics, who works at a health insurance company (a big regional monopoly player), who believes Obamacare is a Trojan horse stepping-stone to full-on govt run healthcare.

              1. hunkerdown

                Never attribute to conspiracy that which can be explained by a perversely skewed payoff matrix… and/or mass psychosis.

      1. McMike

        What is even funnier is watching them swing from one extreme narrative to the either:

        – government is inept, liberals are stupid, they can’t even tie their own shoes without a republican to show them the way…

        ** whoosh **

        – there is a monolithic socialist conspiracy pulling all the levers in a genius global master plan…

        ** whoosh **

        It was only a matter of time that the cons would tie the narratives together: being inept and stupid is part of the socialist genius master plan.

        1. hunkerdown

          It’s times like this where a cheeay tribal myth plays on my inner projection screen…

          “When the Great Deceiver came to town, He sorted our people in two groups, took the great chronicles of our history in His hands, tore them right down the middle, gave one half to each half of the people, and commanded each of them to glorify their own people, history, and gods, and to smash the other apostates.”

          Seriously, though, is the reason that synthesis is so difficult to achieve, or for that matter any discourse that advances the issues toward resolution, is that both partisan narratives are based on denying and rejecting the half of reality not approved by one’s own party?

          1. Mcmike

            It is my great pet peeve, this apparent inability of so many people to listen to themselves speak. Or to remember what they said yesterday. Or to care to do either.

    3. JTFaraday

      “It’s strange to me that Cruz and conservatives are so rabidly loathe to “subsidize” the Malingerers, the good-for-nothings, and the lazy, that they distort the real issue”

      I don’t know why it seems strange. Our entire social welfare policy is predicated on the principle of whipping “the lazy” and trying to force everyone into the labor force (or marriage) by effectively threatening their very lives.

      Our social welfare policy has provided the institutional supports to this way of thinking throughout the second half of the 20th century.

      This is just the latest episode, with an even more obvious corporatist distortion, in that it forces you to be a corporate consumer with a positive mandate and not just a probably corporate (or government) laborer, via the default lack of a better offer.

      I don’t know why so many people seem want to participate in this. For sure, I wouldn’t voluntarily do this to myself.

      1. PrairieRose

        “Our entire social welfare policy is predicated on the principle of whipping ‘the lazy’ and trying to force everyone into the labor force (or marriage) by effectively threatening their very lives.”

        Bingo! Plus One Million! Someone gets it! Bless your heart, JTFaraday.

  4. LucyLulu

    A technical point.

    Medicaid is a state-run program, thus specifics vary from state to state, depending on choices made by state legislatures. States must contribute to Medicaid funding, so Medicaid programs are at the mercy of state budget axes. Medicaid care is often provided in clinic or institutional settings (low participation rate of independent physicians due to low reimbursement, high litigation rates). Dental coverage for adults is offered by some states, and not by others, and at varying levels. Children get full coverage in all states.

    California had dental coverage restored for adult Medi-Cal recipients this year. It was a casualty in 2009 of California’s fiscal crisis.

    Medicare provides no dental coverage, ever. Funds come solely from the federal government.

  5. Jim Haygood

    ‘So anyone who tells you that Medicare as we know it — a single-payer system that covers everyone over a certain age — is unsustainable is ignoring the clear evidence that other countries somehow manage to make similar systems quite sustainable.’

    Maybe other countries have properly financed their single-payer systems. But Lyndon Bunghole Johnson’s Brobdingnagian Medicare Ponzi scheme currently has a negative net worth of $27.174 trillion (for Parts A, B and D).

    I didn’t make this up — it’s in the Financial Report of the United States, Table 5, page 188: total of first three columns (HI, Part B, Part D; line labeled ‘Net results — budget perspective‘):


    To put this gaping budgetary sinkhole in perspective, it’s almost exactly ten times the fedgov’s estimated $2.7 trillion in revenues this year.

    Sweating ten years’ worth of extra revenue out of the tax slaves — on top of their existing heavy burdens — could well kill them. Which might be the only thing that could save Medicare and ‘preserve the Union,’ as Bloody Abe commanded us.

    1. ormond Otvos

      I love it when ten or twenty years of possible expenditures are put up against an annual budget, without attribution.

      It saves me reading the rest of the lie.

  6. steve from virginia

    1 – Empire unravels,

    2 – bosses lie about it,

    3 – as unraveling gathers force, the bosses blame it on 3d parties (Iran, Liberals, environmentalists).

    Citizens have reached the limit to the amount of subsidy they can provide for so-called ‘health’ racketeers. Limit means ‘no more’ = diminished returns. The political minuet in Washington revolves around that reality (along with the Keystone Pipeline).

    Medical cartel is as evil as the banking variety, like all the other cartels.

  7. capt dave

    As I pointed out after the bill was signed, a reform that is supported by the doctors, hospitals, insurance companies, drug companies, and medical equipment/suppliers was a fraud that must mean more screwing for everybody else.

    The exchanges will be a joke. I have worked at an nsurance company in middle management. They have an anti-trust exemption to share usage and loss data. They only competed in price before now by varying the fine print in the policies (covereage, deductibles, exemptions). They are masters at moving money around to show whatever profit they want to report.

    As noted in the article, The precedent of being forced by the government to buy something from a private company is scary. Even worse is that the private company will charge whatever it wants and will get it, because the taxpayer will directly pay them the difference between their price and the affordable price. Guaranteed income. Imagine what Goldman Sachs could do with this precedent.

    1. Mcmike

      ahem *cough* vaccines.

      We’ve been forced to buy monopoly private products – and inject them into ourselves – for years.

      1. hunkerdown

        Oh, this is a great time for that, isn’t it, what with CMS in the middle of driving a big coding switcheroo right now (still based, of course, on AMA proprietary information).

  8. Andrea

    When a society is geared to the profit motive in many areas, sickness, ill health, desperation, is a stellar, mind blowing, ongoing opportunity that will never vanish. It will keep on giving.

    People will offer up their last pennies to care for a dying child, they will even go deeply into debt. Or can easily be scammed into protecting themselves from such an event…with really little or no security, paying out year by year, to face ..lack of coverage, flat denial, obfuscating refusals, etc.

    The only question is who gathers the spoils? In what proportion? Who are the competitors? How are they fighting? How does Gvmt. support one or the other? What are the PTB deciding?

    In a society that allows or even encourages exploitation and oppression of the poor or lower middle class, by all kinds of moves and measures (wages, work contracts, banking charges, access to credit, discrimination, control, police and authoritarian moves, etc. etc.), the health care scam is set not only to continue but to RISE.

    Making it more complicated, complex, and opaque (e.g. Obama-Care) serves only to hide what is actually going on, bogging ppl down in all kinds of studies, details, laws, strictures, odd considerations, positions, loopholes, local legislation, endless bureaucracy, minor political fights, lack of coordination between diff. med entities, etc.

    1. Mcmike

      Yes, the more smoke they blow, the more likely you are being robbed.

      Products and pricing are deliberately rendered incomparable, indicepherable, these days. Be it medical insurance, cell phone plans, or power tools.

      Cell phone plans offer an array of options, tie in the phone purchase itself, tack on extras and insurance, offer varying contract lengths with varying penalties… in the end, you throw up your hand and throw a dart.

      Power tools, even, with a spectrum of product price points, features and gadgets, multiple model numbers for the same product, private labels offering the exact same product in a different color… it is impossible to price shop.

      It is impossible in this modern world to be an informed consumer, even if you try. In fact, the harder you try to figure it out, the less you actually know.

      1. Lambert Strether Post author

        People have been led to believe that because the plans on the websites all conform to the same bullet points when they describe their policies, that the health care delivered by each plan will be the same. I’ve linked in the past to a Kaiser study that gave several firms the same specs for actuarial value, and then compared the policies derived from each spec. The policies were wildly varying.

        So, yet another way in which the concept of “shopping” for health insurance is just a Big Lie, that will produce unequal outcomes for people with equal suffering (health care being meant to relieve suffering). IMNSHO, the entire business model for ObamaCare is immoral, which you would expect in policy built on and sustained by lies and betrayal from day one. [/rant]

        1. sgt_doom

          Add to that, Mr. Strether, that we have already seen the Washington, D.C. health exchange jobs will be offshored to India (they granted the contract to India’s Tata Companies), it will be a foreign national who directs citizens towards whatever private health insurance giant they are paid to direct said citizens towards!

              1. Lambert Strether Post author

                Ha ha, InfoSys got the DC exchange contract in July (!) and now it’s missing huge chunks of functionality. Boy would I like to talk to an engineer on this fustercluck….

      2. anon y'mouse

        I call this “The MMORPG Theory of Social Management”

        questing to get the holy sword of Sarcadon, who only spawns every three months on the waning moon, and then only after a series of quests has been undertaking in the proper order.

        I think i’d rather do like that ARchdruid guy, and just go out and work a spell. it will probably function for my health just as well, and save my nonexistent pocketbook.

      3. s spade

        Let me offer some anecdotal evidence from the world of health insurance. Woman 51, in perfect health, spends 3 hours a day in the gym, lives on sweet potatoes and lettuce, spring water. She pays $180 per month for Blue Cross Blue Shield insurance, and the premium goes up 10% every year as she ages. Goes to her doctor with heart palpitations, gets an Echocardiogram. Doctor bills her $325. Insurance pays $149.90. She owes $175. What kind of insurance coverage is this?

        I lived to age 65 with no health insurance whatsoever. I think my total medical bills for 40 years were less than $175.

  9. anon y'mouse

    the slippery slope-

    if a significant portion of the school system is privatized, then you can count this as one of those areas which will be, de facto, just like the ACA mess.

    in some ways, it already is. the “public option” will simply continue to be defunded and degraded up to the point that no one but the destitute will use it, and by doing so they will ensure that they will always remain destitute.

    imagine an educational system set up JUST LIKE medical care is done today. you might think you know what the sticker price is on tuition and books, but then there’s after school activity fees, uniform costs, special dietary needs lunch package plans, the tutor that they had come in to get little Jimmie’s reading score up to snuff who has their own pricing structure, the nurse’s bandaid that costs $80, and a “playground safety upkeep” tax on top of it all.

    1. Jim Haygood

      Imagine an educational system set up JUST LIKE medical care is done today.

      You mean a system where costs inexorably rise faster than inflation, since a cost-plus monopolistic model offers no incentives for competitiveness?

      Hell, we’ve got that educational system in our state already!

      1. anon y'mouse

        i’m not going to get into a debate with you, because I probably would not win it without looking at an actual budget of an actual school system and how it had changed over time, but one can draw some logical conclusions.

        schools are an unusual bit of infrastructure. we require them to do and be everything, and fix society’s ills. we have placed them in a rapidly expanding, complexifying (every area of human knowledge & concern) and technologizing society and expect them to produce adults who can function. and we expect this to be done on the same budget as in the long-ago days when all you needed to run a school was a building and some books.

        if you want to argue that schools should NOT be in the social services area at all, I think you won’t find many people involved with the day-to-day dealing with actual students to be in agreement. Everything in a young person’s life impacts their schooling–from how much food they are getting to how warm they are when studying, to the fragmentation that has happened in our communities. schools have to pick up the slack from this, because basically no one else seems to be doing it, and because these things all impact their “bottom line” (test scores).

        also, I think you’d find that schools have a LOT invested in plant and equipment that they typically do not just walk away from. maintaining buildings alone, and making sure that the roof does not leak nor the students freeze while they are there probably costs significant amounts of money. a private business would probably scrap and sell of these infrastructures, but schools don’t usually have the convenience of doing that due to their being placed in ideal real estate locations from the off. they have to make do and rehab what they have. you can’t always just go and build a new school on the edge of town (unless its suburbia). the land is not there, and the students wouldn’t be able to get to school without hardships.

        I attended one of the most notoriously corrupt school systems in my state. their “problems” stemmed from administrative level corruption–cronies and relatives of managers at the district level giving dream supply contracts to friends and relatives. ratio of administrators to students was the highest in districts in the state at that time. simultaneously, you had art teachers telling students in my high school class that they had literally $4 per student to spend on supplies for the entire term, Spanish teachers who made clear that they were not allowed to use the school’s copying machine to run off worksheets for the class unless over 80% of her students were designated in some special program or other due to their test scores, and a library which had students shelving books shipped in from other schools to make the shelves look full during the time the accreditation committee showed up.

        meanwhile, they were also expecting these schools to “modernize” and get with the new program of modern technology (computers and so on). not to mention deal with new and increasing rules and requirements for safety, testing and other measures every year.

        these “facts” probably tell you that privatization would cure most of the problems. what they tell me is that we expect a mountain of benefits from a school system that has been poorly staffed and funded, from within a society that has vastly more and different problems now than it did years ago. I grew up with many children of teachers, and none of them were living the high life. they were also expected to do more work with fewer resources year after year. if you want to find the source of the “cost” issue, i doubt it is with them.

        colleges are also similar. i note that my tuition is subsidized by the state to the tune of near $20k every year. i can tell you right now that i don’t think i’m personally spending $20k of the states money by sitting in the buildings during class or using the toilet between them. but i do notice that most of the infrastructure in the college is to provide a HUGE amount of services to students who are “away from home” for the first time. if something goes wrong in an 18 y.o. out of state student’s life, they can find a solution for that somewhere on campus. there are huge tutoring centers, activities, clubs, a health clinic, gym facilities and everything else a normal town would need to take care of its citizens, not to mention new buildings for an expanded student body, labs and materials and computers and so on. this infrastructure comes at a price, and unfortunately the layers of administrators who oversee it all (which could probably be cut drastically) do as well. the non-tenured teachers, meanwhile, report to me that they are eligible for food stamps, and usually work in community colleges all over the metro area just to make ends meet.

        so i’ll agree with you that costs are an issue, and probably some (but not all) could be cut, and that some workers involved have a gravy train (but not the ones doing The Work). but i don’t see how privatization will lower costs to the public any more than it has in the prison system.

        1. Mark P.

          ‘Death of An Adjunct Teacher’

          ‘…Margaret Mary was an adjunct professor, meaning that, unlike a well-paid tenured professor … (she) worked on a contract basis from semester to semester, with no job security, no benefits and with a salary of between $3,000 and just over $3,500 per three-credit course. Adjuncts now make up well over 50 percent of the faculty at colleges and universities….’

          ‘As amazing as it sounds, Margaret Mary, a 25-year professor, was not making ends meet. Even during the best of times, when she was teaching three classes a semester and two during the summer, she was not even clearing $25,000 a year, and she received absolutely no health care benefits.

          ‘Compare this with the salary of Duquesne’s president, who makes more than $700,000 with full benefits.’

          Meanwhile, in the past year, her teaching load had been reduced by the university to one class a semester, which meant she was making well below $10,000 a year. With huge out-of-pocket bills from UPMC Mercy for her cancer treatment, Margaret Mary was left in abject penury. She could no longer keep her electricity on in her home, which became uninhabitable during the winter. She therefore took to working at an Eat’n Park at night and then trying to catch some sleep during the day at her office at Duquesne. When this was discovered by the university, the police were called in to eject her from her office. Still, despite her cancer and her poverty, she never missed a day of class.

          Finally, in the spring, she was let go by the university, which told her she was no longer effective as an instructor — despite many glowing evaluations from students. She came to me to seek legal help …. She said that all she wanted was money to pay her medical bills because Duquesne, which never paid her much to begin with, gave her nothing on her way out the door….’

      2. anon y'mouse

        my shorter answer is:

        where do you think that the private school’s profits will come from? if they “save costs” by eliminating waste and corruption (the latter is highly unlikely given all the content on NC pointing out private sector corruption at every and all levels), won’t they just pocket that as profit?

        why is earning some hustler a profit more virtuous than running a public utility? what benefit is there to the public to have every single essential service privatized? the profit comes from somewhere, yes?

        how much of your private phone or internet or energy or medical coverage is the actual cost vs. what you’re actually paying? if these things were run as a public utility, the only “profits” necessary are for maintenance and improvements of infrastructure, right?

        I don’t get how adding a premium onto every single thing necessary to human life is an improvement. organizations can obviously been run for looting from either the public or private sector.

    2. Mcmike

      As soon as Johnny fails an exam, he gets expelled, and no other school will pick him up.

      You pay your fees, show up on day one, and there is no classroom, becuase it isn’t a covered activity.

  10. LucyLulu

    The US spends an average of $8500/person each year on healthcare. Switzerland, which has a healthcare system quite similar to Obamacare, spends $5650/person, and is in second place behind the US in terms of spending. Canada* and Germany come in at third and fourth at $4500/person.

    So, even a single-payer like Canada is costing $400/month/person on average to deliver healthcare. They collect the premiums in taxes however, using a progressive tax system. In any case, it’s a figure to use for comparison, perhaps, when looking at premiums (including any subsidies and out-of-pocket expenses).


    Out of curiosity I checked out the rates here in N. Carolina where I live, compared to my Cobra coverage 10 years ago (since employer does not contribute to premium). I had very good coverage through AIG, who being a very large company, presumably got excellent rates, for $430/month, and was 44, the last time I had a (good) employer plan. (My last employer plan, and we had only one option, required an employee contribution of over $700/month for family coverage.) Through the federal exchange and BCBS, a 40 year old can get top tier platinum coverage, roughly equivalent, for $450/month, and this is 10 years later. It’s a vast improvement over what I could find in the individual market (esp. given I’m uninsurable — fortunately a moot point, as I have Medicare.) And yes, the young and healthy subsidize the older and sicker. That is how large group insurance works, whether employer sponsored, or single payer/taxpayer funded. The low risk keep the costs down for high risk folks (and vice versa).

    I’ve advocated for universal, single-payer coverage and moving away from our cost-inflating fee-for-service reimbursement for over 30 frustrating years and was sick when we got Obamacare. But this is the reality of what we ended up with. Even with democratic control of both houses, single-payer was seen as too extreme by most of the public and still is. Propaganda has demonized “socialized medicine” over the years and depicted it as inherently inferior….. long waits for care and death panels. My hope remains that we will eventually transition to a more comprehensive and efficient system, perhaps using the infrastructure being put in place.

    Meanwhile there have been some improvements already, and the law, with its disruptions to the present system (the first in 35 years), presents possibilities for real change. Different models of care are being tested in local settings such as Oregon, Cleveland, and Camden, NJ. I worked within one myself locally (now defunded by Neanderthal legislators here). States have been given a lot of flexibility in how they implement the ACA, and some are giving the ACA a chance. I’m still optimistic. We may be headed down a different path towards the same final destination. It’s a once-in-a-lifetime opportunity to start chipping away at the monstrosity we’ve built.

    If it doesn’t save money, kills jobs, wrecks the economy, etcera, etcera, etcera, we’ll find out soon enough. More shall be revealed.

    —-BTW, my hunch is Krugman went with Medicaid due to Medicaid’s use of mass bargaining power to get substantial price reductions, e.g. prescriptions and medical supplies. The VA system also has this bargaining power, and is our only 100% (in theory) public system.—-
    *Link in article citing Canada spends $1000/person less uses references from early-mid 1990’s

    1. diptherio

      “…single-payer was seen as too extreme by most of the public and still is.”

      IIRC, support for single-payer was polling in the 60% range when Obummer took office…

      1. Lambert Strether Post author

        Yep. “Medicare for all” polls very well and still does. And why not? (Even if, as commenters have pointed out, it too has flaws, at least its built on sound principles as opposed to being a scam to keep the health insurance companies in business.)

        1. craazyboy

          IIRC, Medicare has a 3% admin cost. As far as I can tell, most complaints are about Medicare fraud. So maybe adding another percent or two to admin cost could fix that.

          Then, as part of Medicare Part D (drugs for everyone), they said the government cannot negotiate drug prices. wtf?! So we pay double the going world rate.

    2. Lambert Strether Post author

      Single payer was not “seen” (not lack of agency) as “too extreme.” Rather, both legacy parties are owned by the FIRE sector. That’s why HeritageCare -> RomneyCare -> ObamaCare made it over the legislative finish line (with a huge assert from soi-disant “progressives” running interference for Obama and suppressing single payer stories and advocates.

      In any case, the ObamaCare launch will provide a teaching moment. Maybe the conservatives are right, and single payer will be the outcome after all, even if Pelosi isn’t a closet socialist!

    3. Lambert Strether Post author

      “Different models of care are being tested.”

      I’ve argued elsewhere that these “tests” are in reality medical experiments performed on people without their informed consent. That’s about as unethical as you can get. In addition, we don’t need to do such tests. We’ve got a perfectly viable model (see chart in post) on the same continent with a very similar culture: Single payer in Canada.

      Therefore, the only possible justification for these “tests” tests is ideological: Trying to stave off single payer by “testing” for profit solutions that, assuming good faith here, provide equivalent medical and cost outcomes as an already proven solution.

      But of course, one should not assume good faith, since the “tests” are skewed: Single payer “tests” by the states are required to get waivers from the Feds, and VT’s “test” isn’t allowed to begin until 2017.

      The “states as laboratories” argument is bullshit.

      1. LucyLulu

        Ideologically, I don’t disagree with anything you say, except that testing out models is unethical when the models don’t change the care that people (theoretically) receive. Reality is that resources are limited and nobody gets everything they ideally should get (including in single-payer systems). The models try to optimize the distribution of care so that more people get the care they need. For example, Camden, NJ. It was discovered that a very small percentage of recipients were using the majority of the resources. By focusing care on them on the front end, e.g. frequent home visits, focus on preventative interventions, the resources they consumed were drastically reduced. That in turn frees up resources that other recipients can now receive. How is that unethical?

        If Model A is currently being used, and a transition to Model B is made, you’re assuming Model A is the proven or superior Model. I wouldn’t even call it the standard model. At best it could be called the one most commonly in use. What we do know is that Model A is inefficient, expensive, prone to fraud, and leaves too many people out in the cold. At one time, Medicare and Medicaid were experimental and unproven, too. I agree that consent should be obtained, though coercion is inevitable as recipients have no alternative, so it would be more along the lines of letting people know general guidelines of new program. Invariably these have been covered broadly in the local news if nothing else. In any case, consent is always obtained before ANY treatment, so it would constitute a redefinition of “informed consent”. On an informal level, many providers, such as myself, routinely include this type of information with new recipients anyways….. what to expect, right of refusal and consequences of same (system may be punitive but doesn’t imply providers are. I never was. As long as a person understands implications of their decision, people are free to refuse treatments that are likely to result in life threatening consequences, and my clients have. Nobody else’s approval, including mine, is required. In fact, I’ve gotten in trouble for being ‘too encouraging’ of patient’s exercising rights of refusal of treatments they find worse than the disease). The only exception is when homicidal or suicidal ideation is present, and even then, additional opinions (and judicial oversight after 72 hours or if police are required…… one time client was threatening staff of group home with knife and police left and said they’d only come back after magistrate issued petition, so they called me to sit with him, he was a new client and I hadn’t met him yet. Gee thanks! So they all left to get petition and me alone with him after we talked 20 minutes or so, but I was okay with it. He had settled down and was showing me the writings and drawings in his daily journal, explaining the delusional jihad content and Islam, of which I feigned ignorance).

        My apologies, I have digressed. My point is that patients have rights, which all providers should be respecting. The system isn’t perfect, and never will be even close to it. But we should always strive for improvement. And if until single payer becomes possible, some Model B is superior to Model A, it would be unethical NOT to use it. And the only way we can know is by trying it out. It’s not equivalent to testing new drugs, where some get placebos or the new drug with unknown (or undisclosed) lethal side effects….. back in the day when new drugs were still being developed.

  11. Mcmike

    I am firmly in the camp that sees Obamacare is a massive corporate subsidy intended to perpetuate the corrupt system, bring it more captive customers, and guarantee their profits, albeit hiding behind a fig leaf of a few bones thrown to the masses (i.e. preexisting coverage – already now baked into the premiums) – ironically allowing the right to call this socialism, having aparently misplaced thier dictionaries.

    However, the GOP may be on to this thing, it actually may suck so bad, that the only possible explanation is that Nansy Pelosi realy is a closet Marxist, and they really are trying to secretly undermine private health care as part of the global communist plot to get everyone on Medicare.

    Something about seling capitalists the rope…

    Damn socialist masterminds.

    1. ian

      I think it was Ulysses Grant that said that the best way to get rid of a bad law was to insist on it’s exact implementation. This is what the GOP is missing IMO. If they really, truly believe that the ACA is that bad and will fail, they should be insisting on its implementation with no delays, waivers, exemptions or modifications.

  12. impermanence

    The notion that you can repair, replace, rehab 315M+ people’s body parts is absurd.

    Soon, you will be able to spend an unlimited amount of money keeping just one person alive.

    The debate should be about the above, not who the medical industry cartels are going to extort to keep this sick care system on life-support.

    1. anon y'mouse

      i can’t comment on you berating The Krug. i had to pay over a hundred smackers for an economics textbook written by the guy, which was full of blatant 9/11 mythologizing that made me so sick i threw it against the wall once. but then again, every single text book i have purchased does that.

      also, i thought it was the most “talking down to the stupid little people” book i’d ever read (he tends to write like that in his column too, so i guess it is his style and i can’t complain), and although it doled out the -known concepts- or accepted mythos of the Economicon religion in the most thin gruel ever imagined, it still made no sense to me for the most part. like it was written about some Platonic ideal world that never existed anywhere before.

      i like Yves posts of the dynamic Steve Keen, and the MMT people at Columbia better, although sadly i am a walking idiot who cannot understand differential equations without much background work.

      textbooks are evil. unless they are source documents or actual studies, i wish we’d do away with them. not to mention, everything I’ve read about textbook companies tells me that they are totally corrupt.

      (sorry this comment was not on point. you can rip Krug all you’re able, as far as i’m concerned.)

    2. Ed S.


      Krugman knows exactly what he’s doing. Define or be defined. Now the comparison isn’t Medicare vs. ACA; it’s Medicaid (with all the baggage) vs. ACA.

      I have a simple rule of thumb when it comes to any investment: if I don’t understand it, I don’t buy it. Any investment that’s so complex I can’t understand it is complex in ways that don’t accrue to my benefit.

      Medicare for ALL. Say it loud, say it proud.

  13. DolleyMadison

    Just got my new insurance packet – 18,000 just for medical with 20,000 out of pocket before my 80% coverage kicks in. No presription coverage. Can you say FU? I can. I will be “going commando” starting Jan. 1.

    1. Mcmike

      Yup. I am right there with you.

      You get catastrophe major medical stop loss insurance, but at congressional cadillac coverage premiums.

      Except… if you do have an actual major medical event (like, say, a heart transplant), they will weasel out of coverage for that too.

      High dedictible individual insurance is good for exactly one thing: you do get the insurer’s contractual discount prices from the providers, instead of paying top line retail like uninsured schmoes. Nothing to sneeze at, but not worth the premiums.

      1. DolleyMadison

        My family doc has already said he’ll give me a discount if I pay out of pocket and gave me a bunch of ‘just in case’ prescriptions to get filled now while I still have insurance. Getting new glasses and other items while still covered as well. My husband even suggested getting divorced since he is unemployed/self employed so that he would qualify for the exchange and thus be able to insure our minor child. I would never but it shows you the desperation…

  14. Ed S.

    Mcmike said:

    I am firmly in the camp that sees Obamacare is a massive corporate subsidy

    Agree — but with a slightly different twist. What we now have is the taxing power of the USG directly in the service of private interests. You get health care (buy yourself or provided by employer) OR the IRS increases your taxes. Cost of service includes byzantine complexity and huge skim. It’s a win-win (for politicians and insurance companies).

    The other “win” is that it will further impoverish everyone not in the top decile. Here’s my rough rule on costs — your Silver policy will cost at least 10% of your PRETAX income. Let’s look at the examples provided by the White House:

    27 YO Single @ $25k – $1740/yr (7%) + 2k deductible = 15%
    Family of 4 @ $50k – $3384/yr (6.8%) + 2k deductible = 10.8%

    For the family of 4, I assumed that the deductible was applicable to the family (which is atypical — my employer covered HC has ALWAYS treated me & spouse as individual entities w/r/t deductibles).

    The ONLY good thing about these plans is the annual cap. At least people will have some chance to avoid bankruptcy (Silver in CA has a max out of pocket of $6400/yr — so our 27 year old will ONLY have a max exposure of around $8k per year (only 1/3 of pretax income).

    The only hole in the plan is this: if you’re generally healthy, you’d go for bronze. If you get seriously ill, flip to platinum (is there any requirement about how long you need to keep a plan? or how long you wait to get coverage? If there aren’t that will change fast)

    Lambert, this is an AWESOME series. Thank you, thank you, thank you

    1. McMiike

      True enough, but as I mentioned in my vaccine reply above, there is nothing new about the government forcing people to buy private products – from vaccines, to motorcycle helmets, to auto insurance, to using debit cards for payments, to God knows what else.

      The government creates captive and mandatory markets all the time. They then use the drivers license, or the access to school, or whatever they can as the enforcement hammer. Hell, they have private prison contracts that guarantee a certain occupancy rate. I don’t know if the use of the IRS for the hammer is even new; I am sure someone can think of another example where they are the enforcer of private deals.

      There is nothing particularly new about it, it is only more overt & brazen this time, and less easily swallowed by the public, than for example vaccines.

      1. Lambert Strether Post author

        But there’s a lot new about the government forcing people to enter this market. People can choose not to ride a motorycycle, and can even choose not to drive a car, can choose to home school. But none of these are potentially life and death matters. As for the IRS, I’ll assert that the reason you can’t think of any examples is that there aren’t any. I mean, I do a 1040 every where, and I can’t think of a single checkbox like that.

        NOTE On the debit payments, it’s vile and grotesque that states farm out, e.g., unemployment insurance to debit cards from which the banks get a cut — maube $2.50 on $100! In fact, it proves my point about the market state.

        1. Mcmike

          Well, I am not sure about opting out, except motorcylces. There is surely a legal principle that I am grasping for here, but certain aspects of life become part of the fabric of life.

          That’s one of the agruments for universal care: that health care is a RIGHT, not some market-created transaction that you can opt out of or do without.

          The argument that driving is a privilege has been used to justify withholding licenses for unpaid child support. I am not sure it is realistic in the modern world to say we can get by without a vehicle, or a bank account for that matter. Not really. In fact, a computer is rapidly becoming mandatory to navigate economic life.

          As for the IRS, let me ponder that. With all the debtor prison rennaisance going on, there’s sure to be an example.

          In the meantime, is there something substantively different about having the IRS impose the fines, versus, for instance, requiring violators to write a check directly to the Treasury?

          1. Lambert Strether Post author

            I don’t think getting care for a heart attack (say) is in the same league as being able to drive a car, even if both are part of the fabric of life. Losing your life is not the same as having to change it. So, apples and oranges.

            1. Mcmike

              Maybe more like big apples and little apples.

              You are arguing , I think, that health care is a right, but that driving is only a privilege. Since you seem to see a bright line between the two, with categorically different concerns to weigh.

              You seem to be saying, “screw the deadbeat dads’ rights, it’s not like they are having a heart attack.” Is that what you are saying?

              I do not see such a bright line. And in the case of mandated vaccines, even less so, since the idea that a family can just choose to home school seems awfully flippant to me. PS – the vaccine mandates carry through to college too, shall they home school college also?

              Look, I don’t disagree about health care as a right or that our present state of “health care” is akin to some kind of mass war criome.

              Where we differ is I am not so quick to dismiss other examples of the state imposing its commercial mandates on lesser concerns.

              It seems really important to you for Obamacare to be unprecedented. I view it, on the other hand, as merely piomeering new frontiers of depravity in a long arc of escalating depravities.

          2. craazyboy

            I think with the IRS it’s more lack of enforcement. Say, the 90 day rule to get loans into MBS trust funds.

            Also, I think the IRS map of the world shows a great big sea monster on top of where Grand Cayman should be.

            1. Mcmike

              Oh indeed, the IRS granting a great big hall pass to the wealthy is no doubt a major example of the IRS’s bias.

              But in terms of the IRS actively going out and acting as an agent of the state’s non-income-related enforcement arm, that is a different question.

              A closer example is garnishments for debt settlement, but I am not sure the IRS has a role there.

    2. Lambert Strether Post author

      @Ed S. Thanks very much. I regard the ObamaCare rollout as a huge teaching opportunity, so that’s what I’m doing.

      ObamaCare is sure to help some people, and probably more people will feel they are helped. So they will become the poster children for the marketing campaign, the “happy customers.” And you know there’s going to be a marketing campaign of national scale in 2014, as part of the midterms.

      That’s why I take the line that ObamaCare cannot help everyone equally (all the more important now that Obama has just said health care is a right). Not only does it have the great merit of being true, it puts the Obot’s heartwarming success stories in perspective. (This is one reason the Republican campaign about sticker shock is so dumb. The other reason is of course they’re going to manipulate the system to maintain their margin. So if the prices are lower, they’ll beat their profits out of the system by decreasing approvals and payouts, exactly like a candy bar manufactuter shrinks the bar instead of lowering the price on the wrapper.)

      “I know your sister was helped. I just want everybody to be helped, just like she was. Why don’t you?”

  15. clarence swinney

    From 1980 to 2009 look at this record
    Reagan, Bush I and Bush II
    917B of Debt to 11,900
    218,000 jobs per month to 99,000
    Initiated our involvement in 10 foreign conflicts
    Carter + Clinton=0 Foreign conflicts initiated
    Surplus to 1400B Deficit
    700B Budget to 3500B

    Obama inherited from Bush II:
    3500B budget and added “huge” increase to 3800B or 8.6%
    11,900B Debt and increased to 17000B
    1400B Deficit and decreased to 635B
    31,000 jobs per month to 40,000. America’s # 1 problem
    Bush shipped 3,700,000 of our good jobs to “just” China
    Closed one conflict and promises to close second one next year

    1. Lambert Strether Post author

      Hmm. I’m not clear which parts of the post you regard as not factual? Or why, when the ObamaCare rollout is in essence a political campaign, we should regard that part of the permanent campaign ensconced at HHS to be especially trustworthy?

      1. NotTimothyGeithner

        But “denim” provided a link to “actual” facts as opposed to facts which are not actual! Can you believe SAT verbal scores have plummeted?

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