ObamaCare Discriminates Against Poor People with Cancer (and Obama’s Lying Again)

By Lambert Strether of Corrente.

More lies from Obama on ObamaCare? Film at 11! Naked Capitalism readers are already familiar with ObamaCare’s narrow networks, and how narrow networks restrict access to specialists for those thrown into ObamaCare’s shopping experience. Now it turns out that ObamaCare’s narrow networks apply specifically to cancer treatment, and that poor people with cancer will be less likely to be able to select policies that could save their lives. As we shall see, just because Obama’s Lies have grown more prolix and lawyerly doesn’t mean they’re any less Big.

Here’s Obama’s replacement verbiage for “if you like the doctor you have, you can keep your doctor.” 

“[OBAMA:] For the average person[1], many folks who don’t have health insurance initially[2], they’re going to have to make some choices[3]. And they might end up having to switch doctors, in part because they’re saving money[4].”

 Let’s parse out the words of our Insurance Salesman-in-Chief. (spoiler alert: The worst lies are #3 and #4.)

#1 “For the average person.” Averages are said, rightly, to mislead, as when Bill Gates walks into a bar and instantly raises the average income of everyone there. As we have pointed out in exhaustive detail, ObamaCare relentlessly creates second-class citizens, randomly, whether by income, employment, marital status, or jurisdiction. ObamaCare is a profoundly unjust program, and when Obama invokes the average, he conceals the injustice.

#2 “Who don’t have health insurance initially.” In fact, we don’t know how many people who’ve signed up for ObamaCare didn’t have health insurance ‘initially“; the numbers are soft.

#3 “They’re going to have to make some choices.” Trivially, yeah. That’s what the word “mandate” means. Obama’s verbiage conceals two issues, at least: First, as we’ll see below, the process “folks” (how I hate that Beltway locution) will use to make those choices lacks transparency and discriminates based on income.

#4 “In part because they’re saving money.” I bow in awe to the weasel wording of “in part.” Again, we’ll see more below, but NC readers will already have spotted that people may also have to switch doctors because of narrow networks, not just “saving money,” as Obama would have it.

Let’s break down lies #3 and #4 in more detail.

ObamaCare’s “Choices” Work Against The Poor

The ObamaCare marketplace is a neoliberal ideological construct (“because markets”); its vision of how life should be lived, and not a serious attempt at problem solving with public purpose in mind. (If it had been, the success of the Canadian single payer model in providing equal quality of care for much less money would be part of the discourse; it’s not.) As Corey Robin points out, neoliberals like Obama (“they’re going to have to make some choices”) see shopping as an unalloyed good:

In the neoliberal utopia, all of us are forced to spend an inordinate amount of time keeping track of each and every facet of our economic lives. That, in fact, is the openly declared goal: once we are made more cognizant of our money, where it comes from and where it goes, neoliberals believe we’ll be more responsible in spending and investing it. Of course, rich people have accountants, lawyers, personal assistants, and others to do this for them, so the argument doesn’t apply to them, but that’s another story for another day.

The dream is that we’d all have our gazillion individual accounts… and every day we’d check in to see how they’re doing, what needs attending to, what can be better invested elsewhere. It’s as if, in the neoliberal dream, we’re all retirees in Boca, with nothing better to do than to check in with our broker. … In real (or at least our preferred) life, we do have other, better things to do.

Yves summarizes:

I’m one of those people who hates shopping and regards it as a tax on my time.

The issue, here, is that poor people are less able to pay ObamaCare’s tax on their time, and may end up with policies that are wrong for them, with lethal consequences:

For a new study released today in the Proceedings of the National Academy of Sciences, researchers asked 3,414 Americans a battery of questions about Obamacare. [T]hey also targeted a sub-set that could stand to benefit from the law: people who are eligible for Medicaid, the uninsured, or those who make between 100 and 400 percent of the poverty level and thus qualify for the subsidies to buy health insurance.

The results were bleak—just two-thirds of the overall respondents knew that they had to get health insurance this month or face a penalty. Just over half knew about the exchanges to buy health insurance through Healthcare.gov, and less than half knew there might be subsidies available to help them afford coverage.And less than a third knew about the finer points of the law, like the fact that plans must now offer certain required benefits or that people cannot be denied coverage because of pre-existing conditions.

“Clearly some of those most likely to be affected by the ACA were ill-prepared to navigate the new health insurance environment,” the researchers wrote.

Perversely, insured people and richer people had more knowledge about the ACA, and about how health insurance works in general, than did the uninsured. Knowledge about both the law and concepts such as premiums and deductibles increased with income.

Why would this be?

[Mollyann Brodie, a pollster for the Kaiser Family Foundation] points out that uninsured people are more likely to be poor, so they might be “working one or two jobs, trying to get their kids to school. They have complicated and stressful lives.” That, combined with negative news coverage, might explain the don’t-know-but-don’t-like phenomenon.

(Again, with single payer, as in Canada, ObamaCare’s “tax on time” wouldn’t exist, and the neo-liberals designing the program wouldn’t be making the assumption that every American has a personal accountant to wrangle their paperwork.[1]) Quoting (once again) Wendell Potter on a real-life example of how Obama’s “tax on time” plays out:

And I also know that insurers benefit from the marketplace confusion that “choice and competition” can create. I can assure you that some insurers are counting on you becoming overwhelmed by all the choices and picking a plan that might appear at first glance to be a bargain. But beware: if you’re not careful and pick a plan without really kicking the tires, you very possibly will be buying something that could wind up costing you much more than you ever imagined if you get sick or injured.

That happened to my friend Donna Smith, who as executive director of the Health Care for All Colorado Foundation, knows more about health insurance than most of us. She spent quite a bit of time last fall on the Colorado exchange trying to figure out which plan would offer the best value for her and her husband. If she had to do it over again, she would have taken the additional step of calling the insurance companies directly after reviewing the plans they were offering on the exchange, just to be certain of what her out-of-pocket obligations would be if she had to be hospitalized during the year.

A cancer survivor, Donna knew there would be a chance she might get sick again and need expensive care [Rule #2]. It never occurred to her, though, that picking a gold or platinum level plan with a higher premium would likely have been better deal than the silver Kaiser Permanente plan she opted for and that seemed to be more affordable.

To make shopping for coverage even more challenging, Kaiser and most other insurers offer several silver plans on the Colorado exchange, so Donna had to spend time trying to figure out which silver plan would be the best deal.

Donna told me the she took the time to compare the monthly premiums, co-pays and annual deductibles of each of the silver plans before making her decision. “I felt that the one I chose offered the most coverage I could afford with my premium buying dollar,” she said.

Sure enough, within days after the plan went into effect on January 1, Donna got sick and was hospitalized for a week.

To her shock, she later found out some limitations of her coverage that made her overall financial responsibility much higher.

Smith was clearly very knowledgeable about health insurance, and she was able to pay ObamaCare’s “tax on time.” But what if she hadn’t been? Statistically, it’s clear that a large percentage of the poor people won’t be able to pay what Smith could pay; that some of them will not match ObamaCare policies to their health needs; and that some of them will die when they cannot get needed care. Because markets.

ObamaCare’s “Choices” May “Save Money” But There Are Lives It Will Not Save

The “tax on time” to make choices assumes that the choices given are fair, that the choices are clearly stated, and that the outcomes of the choices are not skewed. Unfortunately, none of this is true. Again, statistically, all of these failures — if failures they are — will have lethal consequences; it’s like ObamaCare is a giant maze that only some rats animal models will be able to run, while random others are “sacrificed.”[2]

First, under ObamaCare, your “choice” — your subsidy and the plans available to you — is based on a formula that’s not transparent. You have no way of verifying or reasoning about what bucket they throw you into!

Incorrect poverty-level guidelines are automatically telling what could be tens of thousands of eligible people they do not qualify for subsidized insurance.

The error in the federal marketplace primarily affects households with incomes just above the poverty line in states like Pennsylvania that have not expanded Medicaid. The mistake raises the price of their insurance by thousands of dollars, making insurance so unaffordable many may just give up and go without. …

It also highlights what some public policy experts say is a troubling lack of transparency in the marketplace’s eligibility determinations.

“It is almost impossible to work back from a decision and see what they did,” said Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities in Washington. Ideally, she said, a notice would say, “We have found that your income for 2014 will be X, and based on that income your tax credit will be Y.”

[T]he official determination letters simply state the amount of your tax credit and resulting insurance premium. “I would have no idea if it’s right or wrong,” Solomon said.

Second, under ObamaCare, this “choice” — the hospitals in your plan’s network — will often be described by insurance companies using deceptive language:

Melanie Lapidus, vice president for managed care at Barnes-Jewish Hospital in St. Louis, home to Siteman Cancer Center, said she doesn’t think patients realize the exchanges offer a more restrictive kind of private insurance.

Lapidus cited Anthem Blue Cross and Blue Shield, which includes Siteman in many of its plans outside the Missouri exchange, but none within the exchange.

“We have had many people say to us, `I picked Anthem because you guys are always in their products, and I assumed you would be in their exchange products,'” Lapidus said. “It’s still hard to tell who is in network and who is not.”

(Partly this is a “tax on time” issue, but it’s additionally a branding issue; the rats animal models consumers citizens actually trusted the Anthem brand. Anthem, of course, is laughing all the way to the bank, where, having minimized its payouts, it will also deposit its massive subsidies.)

Third, and most lethally, all these strictures apply directly to cancer patients. Via CBS:

Cancer patients relieved that they can get insurance coverage because of the new health care law may be disappointed to learn that some the nation’s best cancer hospitals are off-limits.”

In all, only four of 19 nationally recognized comprehensive cancer centers that responded to AP’s survey said patients have access through all the insurance companies in their state exchange.”

“This is a marked deterioration of access to the premier cancer centers for people who are signing up for these plans,” [Dan Mendelson, CEO of the market research firm Avalere Health] said.”

By not including a top cancer center an insurer can cut costs. It may also shield itself from risk, delivering an implicit message to cancer survivors or people with a strong family history of the disease that they should look elsewhere.”

For now, the issue seems to be limited to the new insurance exchanges. But it could become a concern for Americans with job-based coverage too if employers turn to narrow networks.”

So, if you’re a rats animal models consumers citizen with cancer, or with cancer concerns, and you’ve been forced onto the ObamaCare Marketplace (as opposed to being forced into Medicaid or having employer-based insurance) all you have to do for a successful shopping experience is:

1) Pay the tax on time to do your research, or

2) Pay the tax on time by having somebody else do your research, like your personal accountant.

3) Make sure you understand and document your eligibility for plans and subsidies in case you need to challenge ObamaCare’s eligibility determination later (or optimize your application).

4) Make sure you understand the cancer centers (if any) included in your plan’s narrow network.

5) Don’t allow insurance company branding to deceive you.

Oh, and hope the plan doesn’t change next year, so you don’t have to go through the same process all over again.

Of course, with a single payer system, none of these steps would be needed, but we can’t have single payer because markets, that being Rule 1 of Neoliberalism. And since a percentage of rats animal models consumers citizens running the ObamaCare maze will, predictably enough, fail to get the plan (if any) that gives them the care they need, Go Die.  That being Rule 2 of Neoliberalism. 

But do enjoy your shopping experience!


[1] Hilariously, the solution the author of the Atlantic piece seems to suggest would only add additional layers of complexity to the complexity: Creating “health literacy” would require more marketing collateral, more training, more “explainers” (that is, more jobs for people very much like the author). A solution others suggest is to “nudge” people into getting coverage by putting the lowest priced plans at the top of the plan selection lists “to minimize the decision-making required.” Obviously, from the perspective of anybody who swore the Hippocratic oath, this proposal is vile and wrong and demands that ObamaCare be opposed (and its nudge theory advocates pilloried). I mean, shouldn’t people be “nudged” to select the best plan for their health needs, as opposed to the financial (and political) goals of the “progressive” program designers?

[2] In politics, this is called being “thrown under the bus.” 

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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. CB

    The Working Families Party emailed me to cheerlead Obamacare. Gad, are there any honest political types left? At all, about anything? I wonder what their payoff is.

    1. Thorstein

      All the political parties’ platforms promise to make you rich. Except the Greens, whose platform is “don’t mess with Mother Nature”. Some say that’s not a winning platform. I guess that depends on how you define “win”.

      1. CB

        Every one of those “Where Are You on the Political Spectrum” questionnaires I’ve answered aligns me with the Greens. Which regrettably fits to a “T” Will Rogers “I don’t belong to any organized party.” The Greens are not a functioning political party and they’ve had plenty of time to become one, somewhere, anywhere.

        1. PopeRatzo

          You’re lucky. All the political spectrum surveys I fill out have me closest to Maximilien de Robespierre and the Jacobins.

          1. CB

            I do think some participants should be removed from the gene pool. We’ll make that your portfolio.

    1. Jim Haygood

      Here’s a better reason, from the 2013 Medicare Trustees report, page 6:

      ‘The estimated depletion date for the HI [Hospital Insurance] trust fund is 2026. As in past years, the Trustees have determined that the fund is not adequately financed over the next 10 years.’

      And this, from page 7:

      ‘The difference between Medicare’s total outlays and its ‘dedicated financing sources’ reaches an estimated 45 percent of outlays in fiscal year 2013. Federal law requires that the Trustees issue a determination of projected ‘excess general revenue Medicare funding’ in this report. This is the eighth consecutive such finding, and it again triggers a statutory ‘Medicare funding warning.’

      While currently serving 50 million people, Medicare’s finances are a Third World shambles, with a negative net worth in the tens of trillions. One of the seven trustees who signed the report is Kathleen Sebelius, the halfwit who was in charge of the glorious Obamacare rollout.

      You’re doin’ a great job, Kathy!

        1. Jim Haygood

          That’s progressive, alright: an 0.5% Tobin tax, AND a 6% income tax surcharge, AND a 6% property income tax, AND a stepped 3 or 6% new payroll tax.

          This plan would transform the U.S. into a European-style welfare state, with federal spending accounting for about 40% of GDP vs. 24% now. Here are two probable results, in the unlikely event that this bill were to pass:

          1. Widespread secession by most red states (the ones where people still have guns).

          2. An economic depression in the rump U.S. (‘East Obamastan’ running from Virginia’s D.C. suburbs to Boston’s northern suburbs, plus ‘West Obamastan’ along the Pacific coast).

          Hey, sounds like a plan … let’s roll!

          1. marym

            According to the cost studies 95% of families and most businesses would pay less than they do now, and annual savings on healthcare costs due to bulk purchase, negotiated provider reimbursements, and reduced admin would be in the neighborhood of $300-500 billion.

          2. PopeRatzo

            This plan would transform the U.S. into a European-style welfare state

            Great. Where do I sign up?

            1. Widespread secession by most red states (the ones where people still have guns).

            Don’t let the door hit you… Considering those Red States get a lot more back in Federal spending than they contribute in taxes, that would be great for the rest of us. Just make sure you put a up a fence, please.

            2. An economic depression in the rump U.S. (‘East Obamastan’ running from Virginia’s D.C. suburbs to Boston’s northern suburbs, plus ‘West Obamastan’ along the Pacific coast).

            Nah. Won’t happen. If you look at the productivity levels and overall economic activity, you’re a lot more likely to see the flyover states suffer. Where do you think Alabama’s gonna buy vegetables?

            Secession is inevitable. I just wish they’d get on with it.

            1. different clue

              We don’t have bunches of Southern readers here writing neoConfederate comments about secceding. So what is the source of all this antiSouthernitic andiSouthernism? What is the reason?

              Actually, if America undergoes a Red-Blue breakup, most of the so-called Blue states will be revealed to be high population Blue cities surrounded by vast Red hinterlands of smaller cities, towns, and countryside. Does anyone here really believe that people in upper state New York don’t have guns? Or the people beyond Greater Detroitistan in Michigan?

              1. different clue

                And Oh! . . . by the way, the part of California which grows the vegetables is Red. And some of the people there have guns.

          3. Me

            So somehow paying more out of pocket is far better and more financially sound than paying less through tax dollars for more comprehensive service, within a far more efficient system? Wonderful.

            As far as the Southern states, they all get more in services than they pay in taxes and the more “liberal” (whatever that means these days) states pay more in taxes than they get back in the form of services. The South would revolt over not paying insanely more to an inefficient and criminal health care system? Can think of no better way to parade around their ignorance.

            While the South is at it, maybe they can revolt if the US doesn’t give away the store to the pharmaceutical oligopolies at the TPP negotiations, would make about as much sense. “Either you extend the patents on life saving drugs, allow a larger mark up price or we’re out of here!”

    2. Banger

      It is not just the politicians that oppose any reason-based HC system for the USA it is also the people who fear that such a system would be too expensive. The fact is that all the mainstream media from Fox to NPR are now and were five years ago virtually fact-free on this issue. Thus stirring up the pot a little with racial fears nearly always works.

  2. abynormal

    i was recently asked by a friend to do some private research on Gambling Addiction.
    30 to 35% of Gambling Addicts commit suicide, where only 15 to 20% of a alcohol or drug addicts commit suicide.
    Gambling, a high physical stressor causes early Heart Attacks and Strokes (no death certificate is ever filed: ‘Died From Gambling’)

    …SO, while im living & studing our Health Industry, im finding myself in Speculation Mode = Gambling. Living thru it while caring for my dying Parents = Gambling Addict.

    im very busy too…removing 20yrs off my life. How many more years will ‘Plan Seeking’ add?

    Thanks for the workup Lambert!

    1. diptherio

      Aby, perhaps the difference in suicide rates between gambling and drug addicts is a result of gambling’s extremely dichotomous nature. Whereas drugs only ever hold out hope of a temporary high, gambling offers the allure of permanent wealth, “the hundred-bagger,” as craazy would say. I live with a few poker players and am quite familiar with the mentality. Contrariwise, the down-side or crash from drug use is limited just like the high, whereas a bad gambling crash can land you, lickety-split, out on the street. The stakes with gambling, both positive and negative, have the potential to be much more life-altering and permanent than even the best (or worst) drug trip.

      Also, it seems to me like gambling addicts also have, or develop, rather self-centered personalities. Not that they’re a-holes in real life, necessarily, but they tend to see the world in starkly competitive terms; they realize that their big win is someone else’s big loss, and they’re fine with that. I think that attitude, which devalues the lives of others, ends up also devaluing their own life. Drug addicts, OTOH, tend to be too hedonistic for all that, whereas gamblers tend towards masochism, far as I can tell (at least the addicts). That’s my anecdotally-based armchair psychology.

      1. abynormal

        Excellent points Dep. Both addicts have the common ‘Chase’ mentality…breeds that charm out of the narcissist, eventually. the danger in the gambling addict (not every gambler is an addict…this i understand) is in the stealth. they charmingly wipe anyone and everyone out of everything. drug adds. will do the same but the signs are visual and hopefully get the ‘choice’ to feed their beast.

        Thanks, I’ll pass the 411/911 along.

        1. diptherio

          “they charmingly wipe anyone and everyone out of everything.”

          Well, I think that depends on the specific person. In my case, the one outright gambling addict in my life is also an alcoholic, so he’s often too sauced to be suave. He does, however, have a habit of borrowing money from people dumb enough to lend it to him and being rather random about the repayment schedule.

          But plenty of gambling addicts are more clever/less impaired than my friend. And everyone has that internal lawyer to help them justify whatever it is that they think they need to do to fill that need.

          1. abynormal

            im reading about duel addictions…interesting stuff. there’s findings of therapist telling their patients “glad you stop smoking coke. why don’t you take up a hobby… like poker”

      2. Banger

        True drug addicts are victims more of drug laws than their addictions while gambling addiction is closer to a real disease.

    2. diptherio

      Rabbi Nahman of Bratzlav once said, “In my life I have been blessed in that I never needed anything until I already had it.” I think we are all blessed in this way, but that Rabbi Nahman was especially blessed in that he not only already had everything that he needed, but that he also remembered to look around for it whenever he needed something. I think that’s the part that us less enlightened folk often forget to do.

      I hope you find what it is you need to help get you through this rough time, Aby. Hell, maybe if you look around enough, you’ll even find that you’ve already got it.

      {{{{{sending telepathic best wishes}}}}}}}

      1. abynormal

        HA! funny that… i thought of YOU yesterday when i backed into this article…
        Check Your Head by Sally Kempton
        ive been so busy running myself dangerously down that i forgot yoga. im self taught (can’t afford classes) but i went to utube for a Standing Twist…felt so good i went right for eye of needle’) im slowing myself down…its a process. i can’t believe how quick care giving can put you in need of care.

        “There is no fetter like illusion, no force greater than yoga, know friend greater than knowledge and No Enemy Greater than Ego.”

        (sunday’s link thread of idea’s & support pretty much saved my life…thank you Dip)

  3. Barmitt O'Bamney

    It’s a simple rule: whenever you as a buyer are being presented with a dizzying range of options, it’s for the seller’s benefit, not yours. Confusion is the object. To quote the admirable Admiral Ackbar, “it’s a trap!”

    We live in Freedman/Reaganite wasteland where the mirage of Choice is both a central strategy of subterfuge, used to maximize the advantage of powerful collective players called corporations against individuals, and also the ideological shield used to blame the hordes of isolated victims for being plundered by the organized, powerful few: “Hey, you chose this brand/model/plan, and you got what you deserved/paid for. If you didn’t want this, you should have chosen differently. Caveat emptor“, they then add, to top off the mystification with a bit of Latin. Whatever you chose, probably there was a gotcha, either in plain sight or lurking in the fine print. The pea was in fact under none of the shells, the face card stayed in the dealer’s hand the whole time. No matter which option you picked, you’d have been wrong. But since you chose, the consequences are all on you. You’ve only yourself to blame if you’re unhappy with the outcome. That’s what they make us believe.

    1. Banger

      This was alway the poison pill of this legislation and the really, really sad part of this is that it was glaringly obvious at the time. The ACA was cleverly pursued while people were still under the influence of the benign carefully marketed image of Obama as “the One.” In fact Obama and those around him are and were virtual Frank Underwoods (main character in House of Cards).

      One way or the other health care was bound to be rationed based on social class. Virtual death panels will continue to expand. Single payer was never even a remote possibility nor is it possible at the national level because the ACA made the insurance industry more powerful than it was.

      1. Brindle

        I have a higher opinion of Frank Underwood than I do of Obama. Underwood actually does the murders with his own hands rather than delegating the act to “staff”.

  4. ep3

    remember Yves, the more time ppl have to commit to researching every decision in their lives, the less time they have to make informed voting decisions.

    1. jrs

      That and 80 hour workweeks, and then braindead leisure for whatever exhausted too tired to think hours remain, ought to take care of any possibility of grassroots political change.

  5. Cynthia

    I am someone who doesn’t mind paying taxes as long as it’s done fairly and equitably. Which is one reason why I strongly oppose ObamaCare. Individuals who make less than about $15,000/year get totally free health insurance, i.e. Medicaid, at the expense of the taxpayer, and individuals who make less than about $45,000/year get heavily subsidized health insurance through the ObamaCare exchanges. These subsidies are paid for by those of us who pay full price for health insurance.

    The very rich and everyone down to, say, the very upper end of the middle class aren’t burdened by ObamaCare all that much because a very small fraction of their income actually goes towards paying for health insurance. But that’s not true for those of us who are smack dab in the middle in the middle class. $500 to $600/month health insurance premiums is a huge financial burden on those of us making between, say, $46,000 and $120,000/year. That doesn’t include a $6,000/year deductible that must be reached before insurance coverage kicks in.

    Keep in mind, people on traditional Medicaid don’t pay a dime in deductibles, nor do they have any co-pays to pay. Unlike the rest of us, their healthcare is totally free. And as long as their Medicaid plan isn’t being managed by a private “managed care” company, their healthcare coverage isn’t narrowed down to an overly narrow network of providers.That means that if Medicaid recipients, who live in Mississippi or any other state whose Medicaid program isn’t being run by a private “managed care” company, seek cutting-edge healthcare in a state like Massachusetts or North Carolina, their healthcare bill is fully covered, no questions ask. But if most of us with private insurance were to do the same, we would be denied insurance coverage.

    If more on the Left would see ObamaCare for what it is — a regressive tax on the middle class, there would be a lot more opposition to it.

    1. diptherio

      I make less than $15k per year. My state did not expand Medicaid, so I am not eligible for it. The cheapest policy I could find on the website has $200/mo. premiums and $6000 deductible. Even worse than the crappy policies I’ve been offered through (both union and non-union) jobs.

      I understand your frustration, but your phrasing of the issue comes perilously close, in my mind, to a “the poor are getting too much” complaint. The real problem is that the ACA doesn’t even address health care, much less the making of it “affordable.” It requires every citizen to purchase a private product, like it or not. The ACA’s problem is that it was never about health care, it was always about justifying shoveling a bunch of gov’t money into the pockets of insurance companies (and specifically, their executives).

      1. Cynthia

        Your feelings as to what bothers me about our health care system are way off the mark, Diptherio! What bothers me about our healthcare system is that it is overly motivated by profits. We could all have healthcare, not just at any price, but at an affordable price, and regardless of income, if we were to just simply take the profit motive out of our healthcare system. That includes non-profit providers, and that’s what bothers me the most.

        How in the world can hospitals get away with calling themselves non-profit providers when their top administrators are making over a million a year? Why in the world are healthcare companies in general allowed to pay their CEOs multimillion dollar salaries when a very large portion of their company earnings come from the taxpayer?

        People would be up in arms if their taxes were being used to hand out multimillion dollar salaries to school administrators; so using the same logic, they should also be up in arm just knowing that their taxes are being used to hand out multimillion dollar salaries to hospital administrators, but for some strange reason they’re not. People don’t seem to be the least bit troubled by this. Maybe if they thought of hospital administrators as government employees, which in a truly significant sense they are, they would be up in arms over this.

        I’m not suggesting that we nationalize our hospitals, or our healthcare system as a whole. Nor am I suggesting that we remove all healthcare companies from the stock exchanges. But if our goal is to have quality healthcare at an affordable price, then I suggest that we first reclassify all healthcare companies as slow growth utility companies. They should be profitable enough to pay expenses and provide their CEOs with upper-middle class salaries, but not profitable enough to make them filthy rich. Marilyn B. Tavenner, the head of CMS, and Kathleen Sebelius, the head of HHS, both make about $200,000 a year, so that’s about what all healthcare CEOs should make a year.

        Healthcare costs are destroying our competitiveness in the world and are bankrupting us as a nation. Taking the profit motive out of healthcare is the best and perhaps only way to reverse these two ominous trends.

        1. diptherio

          I think we generally agree. What rankled me a little in your first comment was the implication that Medicaid recipients having no deductible is somehow unfair (when what is unfair is anybody having to worry about deductibles). I worry that comments like your first one only tend to promote resentment between poor and middle-class people. You are right that the problem is the for-profit system itself.

          I’m just saying that there are lots of things that are unfair about being poor; not having a deductible for your Medicaid coverage isn’t one of them. Even getting close to implying that it is raises my hackles a little. Thanks for clarifying.

    2. Cynthia

      This is why I think ObamaCare subsidies for monthly premium, as well as for deductibles and co-pays, should be patterned after the way federal income taxes are calculated. That way subsidized monthly premiums, as well as subsidized deductibles and subsidized co-pays, would gradually taper off, just as federal income taxes do, yet in reverse of course.

      As it now stands, Medicaid benefits suddenly drop off for individuals making more than about $15,000 a year, and subsidized monthly premiums suddenly drop off for individuals making more than about $46,000 a year. The Medicaid program should be completely scraped and replaced with a program where by able-bodied individuals making less than $15,000 a year can instead purchase health insurance on the exchanges like all other able-boded Americans drawing an income. Oh sure, due to the enormous subsidies, their premiums will be calculated out to be very low, as well as their deductibles and co-pays. But at least they will have some skin in the games like everyone who is drawing an income.

      By the way, there are two other reasons why Medicaid expansion should be scraped, IMO. Its benefits vary widely from state to state and aren’t transferable from state to state. Medicaid also has an “estate recovery” feature built into it. Not even Medicare has such a predatory and sleazy feature built into it! This means that if you are on Medicaid and you die at age 55 or older, the state can confiscate your assets, including your house, and liquidate them in order to cover the costs of your medical expenses.

      1. nan

        I work in health care and about five percent of the population would die if Medicaid was scrapped so income taxes (top rate always getting the largest share) were cut. The fact is, wide swaths of the population are too brain damaged from low-income living and do not have developed faculties to live normally. They require large percentages of health care. Pain drugs being marketed to patients also increase drug costs, accounting for maybe 30 percent of these patients–the rest being premature hypertension and diabetes meds…Sometimes I wonder if, beyond the usual syphoning of tax dollars to private coffers, the elites feel they must put a band-aid on this problem to keep the illusion of progress or sustainability of the system.

    3. Banger

      Cynthia, the ACA is far more than a tax on the middle class–it is a tax that goes directly to the worst elements do our society who have made the U.S. health-care industry the most wasteful in the world and one of the worst, in general, in the developed world.

      I agree with you about Medicaid. It is a system designed to upset those who make too much to qualify and therefore keep the poor hating those who are a bit poorer–this intentional and works perfectly to keep the right permanently in power. It also provides perverse and cruel incentives to stay on Medicaid particularly with a sick child or family member because the alternative is to be forced to deal with the slick. Insurance companies who are incentivized to give you the worst care possible.

      The obvious solution would emerge if Americans understood that a healthy and less-stressed population benefits everyone–but Americans are still obsessed with the culture of narcissism which makes us so easy to manipulate.

      1. Cynthia

        I agree with you 100%, Banger, and it sounds like you also agree with me that the ObamaCare provision to expand Medicaid is a step in the wrong direction. First of all, this provision has shifted the responsibility of providing healthcare benefits to low wage workers onto the taxpayers. Taxpayers fully covering the costs of healthcare for American workers earning less than $15,000 a year, or American workers with a family of four earning less than $32,000 a year, is corporate welfare for corporations that hire a disproportionate number of low wage workers. Expanding Medicaid to low wage workers will also encourage other corporations not to pay their employees more than $15,000 a year, resulting in significant downward pressure on wages in all sectors of the US economy.

        Second, healthcare providers agreed to the expansion of Medicaid only if Medicaid reimbursement rates were increased to match that of Medicare reimbursement rates. But these inflated reimbursement rates are only good for three years. After that, they expire and return to reimbursement rates that are only about 60 cents on the dollar, which is much too low for healthcare providers to stay out of the red financially. After three years, this will definitely act as an enormous shock to our healthcare system.

        Third but equally important, why should individuals making $15,0000 a year pay absolutely nothing for their healthcare, I mean nothing, no premiums, no deductibles, no co-pays? This seems particularly unfair and inequitable given that individuals making $46,000 a year get absolutely nothing in terms of subsidized healthcare, much less free healthcare. This applies to premiums, deductibles, as well co-pays. There is nothing fair and equatable about someone making $15,0000 a year getting totally free healthcare, while someone making $46,000 a year paying full price their healthcare. This will no doubt lead to a lot of tension and strife between low wage workers and middle wage workers. After factoring in the amount of money they have to fork over for healthcare, middle wage workers probably believe, and rightfully so, that they would be better off being low-wage workers. Perhaps this has been planned all along by our corporate elites.

        1. Banger

          Good analysis.

          Here is my perverse take on all this: it is insane, the whole system, whether health-care or anything else, is designed to be craaaazeeee. This makes sure that the ideology of American Exceptionalism remains intact.

  6. katiebird

    And the shocking thing to me is that all this choice stuff is true for Medicare coverage. …. Do we need a Supplemental Plan (it would seem so) ….. then WHICH supplemental plan (out of hundreds) ….. And Part D – the prescriptions, yet ANOTHER choice!

    It is making my stomach hurt. Apparently there is a county volunteer group to help out. But, just getting in touch with those people is taking multiple phone calls on both our sides.

    I hate this. Choice when it comes to health insurance sucks. bleh.

    1. Carla

      The crapification of Medicare really gained steam with the introduction of the Part “D” prescription drug “benefit” under Bush and Teddy Kennedy, and has accelerated since Obamacare was first devised by insurance industry lobbyists in 2009. Moreover, Obamacare has conveniently eclipsed this ongoing crapificaiton of Medicare for the last five years. I suspect this has all been according to plan.

      1. Peter Pan

        Those recommending Medicare for all apparently don’t understand the degree of crapfication of Medicare through supplemental insurance, although I believe their intent is well meaning.

        My mother has Medicare and every year she goes through a maze of insurance possibilities that makes Obamacare complexity appear simple. We need a simplified national insurance program for all where the government has the responsibility and authority to negotiate to the citizens benefit. The complexity of policy options presented by health insurance companies is a financial innovation that is nothing less than innovation in fraud, whether it be Obamacare or Medicare supplemental insurance.

          1. katiebird

            And sadly, includes a 15 year implementation schedule. It may be selfish of me but, it makes me sad that our best option is highly unlikely to be implemented in my lifetime.

            1. marym

              Title V Section 501 – Most of the bill (particularly insurance coverage) has a 1 year implementation schedule, “except where noted” (the only reference to 15 years is for compensation payment for converting for-profit care providers to non-profit, there’s a 10 year period before determining if VA should be merged, 5 years to merge Indian Health Services).

        1. Lambert Strether Post author

          We’re aware of it. The question of which is better as verbiage — “Medicare for All,” or “universal single payer” — is a permathread in single payer circles, since 2009 at least. It seems that “Medicare for All” has more resonance for non-geeks. But we geeks are very mindful of the neo-liberal infestation of both Medicare and Medicaid.

      2. jrs

        The ACA of course also took money directly away from Medicare. Obama really needs to get his hands off our Medicare.

        1. different clue

          The whole reason for that was to further the process of crapifying Medicare to the point where people come to see no value in it. Obama’s long-range aim is to see Medicare Ryanized and Voucherized by his successors.
          That is part of what Obama expects to be paid for after he leaves office.

  7. Stephen V.

    Speaking of ‘enjoying the experience’ Lambert! — here is the [one of?] firm retained by the gov. to evaluate the care administered to consumers:
    My ER Nurse-Practitioner client informs me that all of her work is periodically rated [Likert scale?] 1 to 5. So let us say I am seeking pain meds and the NP looks up my history & sees I’ve been to the ER 4 out of the last 5 months for said meds. Guess what nursie! I’m scoring you a 1 across the board! Why does this matter? FUNDING is tied to these survey ‘results.’ I think we must add ‘kabukification’ of the gov’t. as a subset of crappification. As usual, can’t make up this crap. Instead of independent audits, we get fellatio.

    1. Cynthia

      The decision by health-care insurers, spearheaded by Medicare, to reimburse hospitals according to patient satisfaction scores is just their way of perpetuating the age-old myth that our health system is based on free-market economics. Apparently they don’t understand that by encouraging hospitals to turn themselves into five-star hotels adds unnecessary costs to providing medical care to patients. It would be better for insurers to discourage hospitals from wasting money on frilly things such as providing massage and pet therapy to their patients and dishing up five-star meals to them. But they’d never do this because cutting these and other sorts of frills out of health care smacks of socialized medicine.

      This still doesn’t stop me from hoping that when health-care dollars shrink to the point where hospitals must decide between cutting back on providing patients with top-notch food and entertainment and providing them with top-notch medical and nursing care, they’ll choose to do the former rather than the latter.

      1. Banger

        Makes sense–however I take exception to your characterization of massage as a frill. Touch is often better than drug therapies in many areas.

  8. floydd

    SINGLE PAYER belongs to the century of MODERN countries! How does disappointment w/ Obama help to fix the problems we recognized here. Personnaly, I am sickened by the adoption of the Regan template for economic recovery. And yet recognize what can and cannot be done! Without crossover voting by (non-GED) educated publicans our similarities to our old cold war foes will but deepen.

  9. LAS

    Dear Lambert,

    I think your efforts to discredit the ACA are not well informed. You need to think about the deteriorating insurance market, health disparities and health outcomes in the country BEFORE the ACA. You need to appreciate how many people were dying from medical errors and what the incentives were behind those errors (see the Institute of Medicine’s lower bound estimate in “To Err is Human”). Your writing objective seems to be discredit Obama and not the public health transition we need to accomplish in this country for the betterment of all.

    Open your eyes wider. It is not surprising that Obama might be attacked for mis-communicating because the landscape is extremely complex and highly politicized.

    To begin with, we now have the beginnings of a regulated insurance market, approaching public utilities. We did not have this before. We have protections from recissions, from exclusions due to pre-existing conditions, from lifetime caps and more. Insurance companies have to rebate $ if they over-charge us. The fact that this new market isn’t free/cheap or single payer is something you’re going to have to get over. We don’t get free electric power and water either.

    In ACA we also get the government beginning to use its huge buying power authority through Medicare to demand more accountability from healthcare providers. We have the gov. trying to address workforce issues. In fact, we do have a lopsided physician workforce in this country and we do NOT need more big city fancy specialists but community based general practice doctors. Physicians need new incentives such as per capita payment and wellness bonuses instead of fee for service so that they will concentrate on keeping the population healthier as apposed to over-medicated, etc. These changes are happening under ACA.

    We need hospitals to be more accountable and pharmaceutical companies to be more accountable. These changes are beginning under ACA.

    You also need to understand the complicating factor the Supreme Court introduced when they permitted states to resist Medicaid expansion for the poor. Attackers of the law are enemies of healthcare access and dignity for the poorer among us. And if you have any doubt about the kind of civil war that is being subtly played out under the guise of political debate over this legislation & Medicaid expansion, just look at a map showing which states are expanding or embracing the law versus those resisting it. Then look at the disparities between states as to who qualifies for Medicaid. The disparities that resistant states want to preserve are truly appalling.

    ACA is a huge piece of legislation and you’re sweating the gnat while you swallow a camel.

    1. NotTimothyGeithner

      Lambert has a whole series on this issues of ACA, and once again, the Obots have another feeble attempt to discredit informed criticism.

      Guess what? The problem with ACA is we still have the sa me for profit system with taxes being directly handed to insurers.

      When did you address the points raised by Lambert or offer fixes that Democrats promise? Oh that’s right never.

    2. Cynthia

      Eventually our crony capitalist healthcare system will break the backs of the US taxpayers, sending our country into irreversible bankruptcy. Don’t think that cost containment is gonna step in save the day. Believe me, the ten dollar a pill Tylenol is not going away anytime soon. That’s because ObamaCare encourages too much costly bureaucratic growth in the back offices of hospitals to ever let the cost of Tylenol fall back to free-market oriented prices.

      Keep in the mind, Tylenol doesn’t cost ten dollars a pill because the hospital nurse who administers it is paid too much, or the hospital pharmacist who dispenses it is paid too much, or even the hospital doctor who prescribes it is paid too much. Tylenol costs too much because for every doctor, pharmacist or nurse employed in the hospital, there are ten or twelve dead weight bureaucrats and administrators in the back office, sitting on their duffs pulling down 6 figures a year. ObamaCare does nothing to rein in these unnecessary costs in hospitals. If anything, ObamaCare encourages these unnecessary costs.

    3. Banger

      There is some merit to your argument but I think you are a bit off base. First the ACA “debate” never took place. Ideas, facts (the many diverse and reason-based systems around the world were barely mentioned), science largely ignored by the WH. And the media except as they encourages us to think about this as insurance reform rather than health-care reform. There is no rational argument for our current system pre- or post-ACA. It is something that resembles something that might have come out of the royal court in Alice in Wonderland if you compare it reality-based systems.

      While some of the reforms you mentioned will relieve some suffering this is done by increasing a good deal of long-term suffering due to preserving the dominance of the predatory and criminally-minded insurance companies with riches in perpetuity. I don’t think there is any reason to believe that the regulations that will emerge will do anything other than enrich that sector and further screw up the system–to be crude, you don’t hire the SS to try to moderate anti-Semitism. Why should health care regulators really police HC any more than financial regulators regulate the finance industry when the revolving door is the order of the day at every level of government?

      Had ACA not passed, I believe there would have been a myriad of local solutions centered including alternative healthcare modalities, clinics, and various private/NGO/professional/governmental partnerships that would have moved into a less wasteful system. I believe a coherent system could have emerged because the non-predatory parts of the system were very unhappy an they were trying to change thing. Instead Obama made a deal with the most toxic part of the system.

      I urge you to read Lambert’s articles on this new system in which he addresses some of your concerns.

    4. Lambert Strether Post author

      Some believe equity demands that health care be accessible to all citizens, equally. ObamaCare advocates don’t. In particular, you don’t. It really is that simple.

      1. NotTimothyGeithner

        I don’t think it’s accurate to say Obots don’t believe in universal health care and unicorns. It’s just irrelevant to them. Their motivations are centered around the glorification of Dear Leader as opposed to any outcome. They remind me of lost tribes who don’t have experience with concepts such as time or how woman get preggers which amused British explorers in Australia when their aboriginal guide returned home after a year and a half to witness the birth of his son.

  10. Seal

    The American people have a President and Congress with their OWN Cadillac health care [and retirement] plans. this is “health care” for the rest of us.

  11. Pat

    Had a couple of moments with friends recently who are going to have a couple of facts I laid on them eat away on them. First was the person who went on a rant about how every Doctor and hospital should be required by law to accept Medicare, Medicaid and be on the networks. He had just had to search for a doctor in network for an issue. Had to have it explained to him that the limited networks in his case were not about selfish doctors not choosing to be a part of his available network, but were probably a direct result of his insurance company limiting the number of doctors in his network in order to limit access to health care. (And yes it was to figure out if something was cancer.)

    Other moment was when a friend asked me if I had gone on the exchanges and checked because her husband had gotten medicaid (she made enough last year for her union coverage but not enough for her husband’s). I looked at her and then pointed out that I’m between 55 and eligibility for medicare and if I wanted everything I owned to belong to the government I’d just stop paying taxes. I then informed her that beyond that I did check and I qualify for a minor subsidy, but that I wouldn’t have even gone near the exchanges if I was close to the Medicaid income levels because of the fact that the government was allowed to take everything you own. She still hasn’t probably wrapped her head around the fact that they might have a minute to get themselves out of this, their ages are on their sides. But I’m betting when this comes up with her brother, he is going to slap some sense into her. He’s the one who took care of making sure their mother’s property didn’t fall prey to possible Medicaid coverage if she needed more rehab then Medicare covered. Once he starts demanding that her husband’s name be taken off EVERYTHING. I think the blinkers will drop a little.

    More and more, people are going to figure out that NONE of this is about health care and all of it is about profits for a few – including the medicaid expansion.

      1. allcoppedout

        dong the witch is dead.
        Some of my US undergraduates doing the year abroad thing were middle class pretending to be poor 25 years ago (making funding applications as living with a pensioner grand parent sort of stuff). Obamacare will no doubt be similarly juked.

  12. allcoppedout

    Strangely, as a beneficiary of UK NHS, I feel government has less to do with my healthcare than you in the USA. Even here 7 – 15% of the budget is fraud. As to Cynthia’s ‘backroom blodgers’, I agree – yet the most prominent use of this claim here is by our Tories – they are always claiming we can cut such excess and not harm front-line services, though it seems cuts always do. But then, I understand so little economics I can’t get past why a thrusting private sector needs the counterweight of 20% real unemployment. Or why USUK has to steal so many doctors and other trained employees from other countries, given our wonderful education systems.

  13. The Polemicist

    Obamacare is not a public program, but a government-assisted private boondoggle. Its main purpose is not to ensure public health, but to insure the profitability of private health insurance companies and the private pharmaceutical and hospital industries.

    It’s as if a president who had promised a new, progressive public transportation system, ended up forcing everyone, under the threat of a tax penalty, to buy a car – a Ford or a Lexus or whatever, you choose – from the same network of dealers that’s been gouging you all along, adding: Don’t worry. I’m going to make sure that every car you buy has brakes, seat belts, and turn signals. What’s more, I’m going to make sure (kinda, sorta, maybe, for some of you) that you are offered an affordable monthly payment. I’ll even help you make the payment if you’re really strapped, by giving public money to those car dealers. Now, a steering wheel, that’ll cost you a deductible. A heater? Copayment.

    Would anybody think that this was a solution to the need for a public transportation system? Any of the public that had demanded such a system? Any of the thousands of activists who had been working for it? Only in America.

    You can repeat the analogy ad infinitum: Want a good public water supply? We’ll help you buy bottles of Dasani and Poland Spring. That’s the neo-liberal formula.

    It’s a system that won’t work well for anybody it pretends to serve, and will perpetuate enormous social inequalities in the access to healthcare.

    The wrinkle is that, as we are seeing Obamacare failing politically, there is a very good chance that it will fail in its actual socio-economic goal of maintaining the profitability of the private health insurance industry – in other words, failing the capitalist interests it intends, as much as the people it pretends, to serve. A lot of young, healthy people – I’m guessing millions – are going to do the math, and realize it will cost them less to pay the interest- and penalty-free tax penalty (that may never be collected), and forgo paying insurance premiums until they get sick.

    Which means millions of people will remain uninsured, and end up paying more taxes for that honor. This is absolutely ridiculous. Should people not be pissed off about this? Why shouldn’t any extra tax you pay end up buying actual health insurance? Because the minute you ask that question, and think about it for more than three seconds, you end up with some form of Medicare-for-all as the only sensible answer.

    But this also means trouble for the health insurance companies, and the whole contraption. A Reuters article emphasizes the concerns that “the market won’t attract enough young people to keep it financially viable, putting more pressure on government funds to compensate for any insurer losses.” Such “compensation,” in any form, however, would further destroy the program politically

    There’s a pernicious, and I think deliberate, side-effect to the jumble of regulations, penalties, and subsidies: It is another contraption for reproducing class, really intra-class, resentment and division. A worker whose income is a bit too high for any kind of subsidy, will probably have to choose the plan with the lowest premium, and will also have to pay for every penny of deductible and co-insurance out of his her own pocket. The barely-making-it guy or gal is going to see some folks with less income getting bumped into better plans because, in a given venue (Different everywhere!), a family that qualifies for all the subsidies may be find it cheaper to opt for a Silver plan with a nominally higher premium. S/he may not feel so great about that. This is the kind of intra-class resentment that these kinds of means-tested, particularized purchase plans (as opposed to a simple universal-coverage plan) foment – and it is exactly what they are intended to foment.

    The idea is to get these two people, whose incomes are an inch apart – and not in the same galaxy as Joe Swedish, Wellpoint’s CEO, (who “earns”: a $1.25 million salary, plus possible $3.75 million bonus, plus $8 million stock options, plus $3.56 million “compensation” for leaving his last job) — fighting over who gets one dime more from “the government.” The idea is to keep them clueless about the fact that it’s Joe Swedish who is getting all the money from the government, and to prevent them from ever thinking about how everyone can get healthcare coverage that’s equally good, if we’d just leave Joe out in the cold.

    Bottom line: Obamacare is a system that’s fundamentally irrational and unjust.
    The sole focus of healthcare progressives now must be to promote a true single-payer, universal coverage, Medicare-for-all system, which means – There’s no avoiding it! – quickly and thoroughly ending Obamacare, along with the parasitical $2.6 trillion profit machine that produced it, and that it sustains.

    See the detailed critique at Who’s the Boss?The Obamacare Deception.

  14. Dana

    I think it’s more accurate and less inflammatory to say that the ACA helped both rich and poor while failing to do much of anything for the middle class.

    I mean, what was your insurance premium on your pre-ACA plan? Right, you couldn’t afford it, so you went bare. Pre-ACA, private insurance with similar nominal coverage levels (albeit much more inclusive provider networks) cost double or triple a minimum-wage worker’s ENTIRE annual income. Wealthy individuals who’ve converted to ACA-compliant plans are now saving $1,000 per month or more on their insurance premiums. Bonus – since they don’t qualify for subsidies, they can buy the exact same plans off-exchange for a lower premium. Meanwhile, it’s hard to lay certain states’ refusal to expand Medicaid at the feet of the ACA, since the statute as enacted didn’t permit that refusal.

    The greatest burden the ACA imposes on the middle class has yet to be felt, in the form of the so-called “Cadillac tax.”

    1. The Polemicist

      Re the observation that it “helped both rich and poor while failing to do much of anything for the middle class”: There’s truth to that, as both this post of Lambert Strether’s and mine linked above point out, but, as Lambert makes clear, the “help” only comes to the poor after they jump through a lot of hoops they are not very adept at dealing with, and it’s “help” that allows poor clients to be pushed around in ways they can’t anticipate or control.

  15. DolleyMadison

    “Where do you think Alabama’s gonna buy vegetables?” Um, seriously? You think folks in Alabama don’t know how/don’t have the climate to grow vegetables?

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