ObamaCare Post-Victory Lap Cooldown

The captains and the kings depart, the tumult and the shouting dies, and we and the press have weeks ago moved on from the days of Democratic triumphalism over ObamaCare’s 8 million sign-ups; from ObamaCare’s exhortation that Democrats be “proud” that the ranks of the insured are now about 2% below pre-depression levels. So now is the time to start framing questions for how successful ObamaCare is as policy, now that the original — and absurdly lowballed — metric for success has been met. (That the press was helpfully complicit in accepting sign-ups as a metric for success is one of Obama’s many public relations triumphs.)

And absurdly — pathetically — lowballed ObamaCare’s initial triumph has been. Here’s what CBO projected for sign-ups in 2012:

CBO and JCT now estimate that the ACA, in comparison with prior law before the enactment of the ACA, will reduce the number of nonelderly people without health insurance coverage by 14 million in 2014 and by 29 million or 30 million in the latter part of the coming decade, leaving 30 million nonelderly residents uninsured by the end of the period (see Table 3, at the end of this report). Before the Supreme Court’s decision, the latter number had been 27 million.

Does 14 look like 8 to you? Did I not get the memo? (Now, you can get to 14 million if you also count those who bought private insurance before the deadline, but (1) that’s not how CBO did its calculations, and (2) that says nothing good about the quality of ObamaCare’s site(s) or its policies.)

And there’s a lot else we don’t know. No matter what the Democrats say, all the coverage numbers are still soft. Health Affairs:

Previous coverage status. One question the [HHS summary enrollment] report does not answer is how many of those who chose a plan were previously uninsured. Information on insurance coverage was only collected from FFM applicants who requested financial assistance, and only was only requested as to current insurance coverage at the time of application. Of the 5.18 million individuals who applied for financial assistance and selected a plan in the FFM, 695,011, or 13 percent, indicated that they were insured at the time of application.

HHS acknowledges, however that this number probably undercounts the number of individuals who had coverage prior to applying to the marketplace, and notes that New York has reported that 30 percent of enrollees had prior coverage while Kentucky reported 25 percent. The report also notes Gallup, Rand, and McKinsey data reporting that over half of marketplace enrollees had prior insurance coverage, but observes that Rand, Urban, and Gallup have reported a significant drop in the number of uninsured Americans during the open enrollment period. It will be some time before we know how many uninsured Americans have been covered through the marketplaces.

So, the Democrats are taking a victory lap without having actually crossed the finish line (and after somehow having worked the refs to turn a 140-yard dash into an 80-yard one). Alrighty then. Nevertheless, ObamaCare is, as the “gold standard of medical journalism” NEJM puts it, in a display of realpolitik stunning for anyone who took the Hippocratic Oath, “here to stay.” They explain:

As long as Obama remains in office, he would surely veto any repeal law, and a veto override is inconceivable. Come 2017, outright repeal will remain unlikely for three reasons. First, all major parts of the ACA except the individual mandate [1]are popular — including the insurance-market reforms, the subsidies to make insurance affordable, closure of the drug-benefit “doughnut hole,” and the incentives [although the mandate has been postponed] for most employers to provide affordable insurance as a fringe benefit. Second, lawmakers who support repeal will not want to snatch insurance coverage from an estimated 37 million people who will be insured thanks to the ACA in 2017. Third, repeal would cut into the sales and profits of health care providers and suppliers of all stripes.

Shorter: By 2016, rent seekers will have fastened their sucking mandibles into the body politic sufficiently to make them very hard to dislodge.

Finally, the administration has, yet again, ruled out single payer, at Sylvia Burwell’s confirmation hearings for HHS head. So, the Republicans now have nothing to say, and they’re not saying it:

House Republicans have no scheduled votes or hearings on ObamaCare, signaling a shift in the party’s strategy as the White House rides a wave of good news on the law.

Not a single House committee has announced plans to attack the healthcare law in the coming weeks, and only one panel of jurisdiction commented to The Hill despite repeated inquiries.

GOP campaign committees also declined to say whether they will launch any new efforts on the law.

Truly pathetic. And after all that frothing and stamping. How times did these bozos try for repeal in the House? 42? So, it falls to those in the wilderness to the left of the Democrats to ask questions. Here they are:

  1. How Many Lives Will ObamaCare Save?
  2. What is the Actuarial Quality of the ObamaCare “Pool”?
  3. Will People Be Satisfied with Their Plans Once They Use Them?
  4. What Will Happpen to Employer-Based Insurance?
  5. What About the Back End?
  6. What About Single Payer?

Let’s take each question in turn.

1. How Many Lives Will ObamaCare Save?

Surely the question of lives saved is more important, from a policy perspective, than sign-ups, which involve, after all, filling out a form and making a payment (ka-ching!). And we have a new study from the Annals of Internal Medicine:

Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study

Background: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear.

Objective: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care.

Design: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions.

Setting: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score–defined control group of counties in other states.

Participants: Adults aged 20 to 64 years in Massachusetts and control group counties.

Measurements: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146 825) from the Centers for Disease Control and Prevention’s Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health.

Results: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults). Deaths from causes amenable to health care also significantly decreased (−4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year.

This is actually very good news! Translating that into English and doing the arithmetic:

The absolute numbers are also striking. The Congressional Budget Office estimates that ACA will reduce the ranks of uninsured adults by something like 20 million people. I rather heroically extrapolated the authors’ 1/830 estimate to the entire uninsured population across the U.S. This back-of-the-envelope calculation implies that ACA will prevent something like 24,000 deaths every year. That’s almost the number of Americans who die in auto crashes. It’s more than the number who die of AIDS or the number who are murdered every year.

I can’t imagine why the Democrats don’t make this figure a key talking point; they are, after all, perfectly happy to talk about a lesser number of excess deaths in Republican states that didn’t expand Medicaid. Perhaps it’s because ObamaCare, when fully implemented, will only cover half the uninsured, raising the unpleasant question of why Obama and the Democrats, in their signature domestic initiative, are willing to throw 24,000 other lives under the bus?

Of course, with single payer — “Everybody in, nobody out” — this question wouldn’t even arise.

2. What is the Actuarial Quality of the ObamaCare “Pool”?

Again, the numbers are soft, and surely vary randomly (like everything else in ObamaCare) from state to state and even county to county. But we’re beginning to get reports. From North Carolina:

Blue Cross was one of only two companies to offer plans in North Carolina through the online marketplace, and as of May 1, 232,000 people were on Blue Cross marketplace plans. Seventy percent of them didn’t have coverage through Blue Cross previously, the company said.

Initial Blue Cross projections called for 50 percent of the marketplace customers to be 34 years old or younger, but after the enrollment period ended on March 31, the company found that only 32 percent of the people who signed up under the federal health care law fit that profile. Forty percent are ages 35 to 54, and 29 percent are 55 or older.

Younger customers are usually coveted by insurers because they are healthier and can balance out the spending of older customers who consume more medical services. But Blue Cross said even the younger customers who signed up for coverage through the online marketplace are sicker than one would expect.

Thirteen percent of enrollees ages 18 to 34 reported experiencing chronic pain as part of a Blue Cross self-assessment, compared with 8 percent for the age group as a whole. Seven percent have diabetes, compared with 4 percent of the group as a whole, and 24 percent said they have depression, compared with 14 percent for the group as a whole.

“The frequency and types of care ACA customers receive and the conditions for which they are being treated are key factors that will determine future premiums,” Blue Cross said in a statement.

So, as long as North Carolina citizens don’t get sick and don’t use services, their premiums won’t go up. Good to know. Of course, with single payer, this issue doesn’t arise.

3. Will People Be Satisfied with Their Plans Once They Use Them?

First, we should take into account the possibility that Obama’s marketers over-sold the people who signed up in the last minute surge. CJR points to a question that never got asked or answered:

Why are enrollees changing their minds? In the push to get enrollees to sign on the dotted line, sales pitches from the White House and its allies may have overpromised. In the days before the deadline, for example, Organizing for Action, a group that sprang from the president’s reelection campaign network, tweeted like crazy. One example: “For Jake, $15 a month on health care fits into his budget.” But, what did Jake have to pay out-of-pocket? Probably a lot! That wasn’t part of OFA’s sales pitch, which had the flavor of those shoddy sales practices that once drove state attorneys general nuts but now seem perfectly acceptable in the context of selling Obamacare. When people find out they aren’t getting what they bargained for and must pay high amounts of cost-sharing, buyer’s remorse can set in, and they junk their coverage. Reporters should find some of these people and talk to them.

“Reporters should,” but will they? This story, on ObamaCare in NH — therefore with a 2016 subtext — doesn’t get around to mentioning ObamaCare’s narrow networks until paragraph 23, which reads:

To be sure, Obamacare faces unique challenges in New Hampshire. Just one insurance company in the small state offered insurance policies through the program this year, and the insurer doesn’t cover healthcare in 10 of the state’s 26 hospitals, deficits Shaheen and Shea-Porter have been working to fix.

Monopolies with narrow networks are hardly unique to NH. Is it too much to ask that reporters — most of whom have employer-based insurance — pay some attention to the actual policies that ObamaCare sells?

Once again, of course, single payer doesn’t have this problem. Shaheen and Shea-Porter wouldn’t have to be working to “fix” anything.

* * *

I’ll cover the remaining three questions tomorrow. If you’ve got experiences with ObamaCare, or the health care industry, to share, please do so in comments!


[1] ObamaCare without the individual mandate is Hamlet without the Prince. In a stunning display of either incompetence or kayfabe-like complicity, the Republicans have never made the idea that forcing people to enter a marketplace is wrong — which eventheliberals, at least of few of them, might have agreed with — a key talking point in their attack. Instead, they relied on the knee-jerk appeal of “ZOMG!!! Socialism!!!!” which was plainly false, and then on the collapse of the Federal Exchange, betting the farm that the administration couldn’t resolve a public relations issue by calling on the tech dudes in its base, the creative class. #FAIL.

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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. financial matters

    From the article mentioned on Sylvia Burwell’s confirmation hearing I think this is a strong endorsement for single payer.. “an approach reviled by Republicans and industry leaders”

    But I think that doesn’t refer to rank and file Republicans as much as to their elite. As many of them enter into “the centerpiece of Obamacare is a private market-based insurance system of state-based health insurance exchanges.” I think it worries the party leadership that single payer may start to look pretty good in comparison.

    I think Lamar Alexander has it right “”Ms. Burwell, you have a reputation for competence. And I would respectfully suggest you’re going to need it,” Alexander said. “The only thing that will be bipartisan about (Obamacare) will be the opposition to it.””

    1. HNPS

      Alexander is pretty much the “mirror image” of a corporatist (DLC) Democrat, as is Bob Corker.

      He and all Republicans “adore” Sylvia Burwell (formerly Asst. Chief of Staff to President Clinton).

      Read recently that a “saying” in Washington Elite Circles (by both parties) is: Where’s a Sylvia, when you need one? (paraphrasing)

      Some Democrats are already on record supporting the repeal of the “employer mandate.” IMO, the public will continue to oppose the “individual mandate”–especially, if Dems nix the employer mandate (which I am convinced that they will do–if not before, after the 2016 election).

      BTW, there are numerous articles talking about “compromise” on ACA reform. Most of the faux attempts to repeal the ACA were “Kabuki”–to mollify the Repubs’ conservative base.

      I agree–both parties will do ANYTHING to avoid enacting a single-payer healthcare system.

      Including compromise–at least “after” the 2016 Presidential Election.

  2. yenwoda

    “Does 14 look like 8 to you? Did I not get the memo? (Now, you can get to 14 million if you also count those who bought private insurance before the deadline, but (1) that’s not how CBO did its calculations”

    The CBO numbers include 9 million exchange sign-ups, 7 million Medicaid and CHIP sign-ups, and a million fewer each in the employer and non-group categories.

    8 million is the number of actual exchange sign-ups so far.

    1. Kent Crawford

      There is a more fundamental difference between the CBO’s estimate and the administration’s 8 million number. CBO estimated 14 million ‘paying customers,’ while the 8 million number is only those who selected a plan on the balky website. That is quite an apples and oranges difference!
      While definitive numbers will not be available for some time, this is approximately what the difference between the 8 million ‘plan selections’ and actual ‘paying customers’ is; an estimated 10 to 20% are duplicates, do-overs, appeals, or ‘window shoppers.’ To be charitable, assume 10%, taking the number down to 7.2 million. Around 20% of those will not pay the first monthly premium, so we are now down to around 5.8 million. Of those, about 5% [as of mid-March] will not pay the 2nd monthly premium. So the 8 million is most likely closer to 5.5 million ‘paying customers.’ And there is a distinct possibility that that number will fall as ‘customers’ cannot make the payments or revolt against the crappy insurance plans…

      1. yenwoda

        I think you’re missing my point. The CBO projected 14 million net sign-ups *including Medicaid / CHIP*. More than once in this piece, Lambert dings the administration for only achieving 8 million sign-ups (“Does 14 look like 8 to you?”; “turn a 140-yard dash into an 80-yard one”), but the 8 million number only includes the exchanges, not Medicaid / CHIP. That is the apples to oranges comparison – between the CBO’s projection of { exchanges (9) + Medicaid / CHIP (7) – employer (1) – group (1) = 14 } and the actual number of exchange sign-ups (which doesn’t include Medicaid / CHIP) = 8. It’s the sort of thing that would characterized as a “big lie” in these parts under different circumstances of authorship.

        1. Lambert Strether Post author

          I will double check in part two. Thank you! What I get for leaving the topic on the backburner for too long. Adding… I’d do this immediately but I have to go garden while I have sun and then fight with the town. Thanks again.

          1. yenwoda

            No problem – appreciate the accountability. Table 3 I think has the breakdown. Not the whole town I hope?

            1. Lambert Strether Post author

              De nada. No, not the whole town, and hopefully not at all. I tend not to be too good in RL at small groups and committees, because I get ticked off too easily (whocouldaknowed).

        2. jrs

          But we could have had medicaid expansion without the exchanges, the individual mandate, basically anything that’s actually obamacare.

          1. Lambert Strether Post author

            Yes. The Dems try to sell the Exchanges on the basis of “the health care law,” including putting kids on their parents policies, but there’s no reason for the bundling. Therefore, the Exchange is there for other reasons (I argue that a Retirement Exchange in the future).

  3. Dan Kervick

    I don’t understand why it would be regarded as shocking , surprising or pathetic that the Republicans have given up on their attempts to repeal the ACA. Their entire strategy was based on convincing people that the ACA would be worse than both the existing system, and any of various Republican alternatives mainly emphasizing the glories of private sector initiative and competition, and the ethos of rugged health care self-reliance. Now that it looks like the weak tea of ACA will be at least minimally better than the previous system, they have no ground left to stand on.

    Occasionally one encounters the weird notion that there is some inchoate subterranean movement of GOP dissidents open to single payer and socialized medicine, and that this hidden force is somehow a significant component of GOP opposition to the ACA. That’s really ridiculous. Any movement toward single payer is going to have to come almost entirely from the left.

    1. financial matters

      The problems with private health insurance are being well chronicled. Republicans and Democrats have their differences but I doubt any of them like being ripped off. The cost of medical care needs to come down but a first good step would be to remove this extractive industry.

      1. NotTimothyGeithner

        Insurance is a bit of a red herring. There are competing and reasonable markets for all kinds of insurance. Health care is more complex, but the primary cost is the hospital cartels who control the prices and the medical professionals. Traveling from city to city for care is an extreme and unpacking hardship which gives the hospital cartels power and none of the blame because the billing to the consumer is coming from the insurers.

        Single payer is better, but the issue is the HMOs which were illegal until a bipartisan coalition led by St. Ted Kennedy made sure we could have for profit medicine in 1973.

        1. financial matters

          I think it’s the opaqueness of the third party private health insurance which fosters this unaccountableness of hospitals and medical professionals. With single payer we would know better what we are paying for. As Michael Hudson points out rent extraction likes to be hidden and have people pretend it doesn’t exist.

          1. NotTimothyGeithner

            I’m saying the hospitals are where there isn’t transparency. They are the ones who control the actual treatment end. Insurers can be replaced very easily and can face competition.

            Building a competitive hospital system can’t occur which means the cartels control what the insurers are being billed. Those hospital ceos are being well compensated for a reason, and amazingly enough, health care costs start to spike in the aftermath act of 1973.

            If the insurer has a problem with one of their mechanics, they will find another because there are mechanics who operate without insurance referrals who would line up to be the insurers referral. Doctors work under an umbrella of one regional company or become concierge pill poppers for people who can afford or emergency care or go on top flight medical tourism.

            One company which controls the industry is a for-profits monopoly, and we shouldnt let them hide behind doctors and nurses while they rob everyone blind.

            1. kk

              Have to disagree somewhat. Most hospital employees are fire at will, their salaries related to the demand of the hospital. Doctors traditionally can move from hospital-to-hospital based on their small numbers and important procedures. The CEO does make too much money, and like anywhere, management grows at the expense of everyone else.
              Still, the main price problem is drug, medical products, and insurers. (I believe physician salaries are only 10 percent of total cost.)

        2. marym

          HR 676 – Expanded and Improved Medicare for All includes a provision that private provider entities must be or convert to non-profit.

    2. Lambert Strether Post author

      Para 1: See the note.

      Para 2: Yes, well, “some say.” I don’t know of anybody who mentioned a movement; I’ve cited Republican single payer supporters in the past. Some think it it “weird” to seek strange bedfellows coalitions for good policy outside the legacy parties; others don’t. YMMV, I guess.

      1. jrs

        There are DEFINITELY registered and republican voting republicans that are if not enthusiastic at least resigned, to thinking single payer would be better than this mess. So that doesn’t exactly a revolution make, but single payer would probably but broadly accepted among the population (even republicans). Of course since we don’t matter anyway and only the plutocrats do maybe that doesn’t matter.

        1. Dan Kervick

          You’re delusional. These are the lunatics you are talking about:


          But I guess if one is obsessed with one particularly inadequate government program one could find strange bedfellows indeed among the people who are committed to destroying each and every part of that government.

          1. hunkerdown

            Dan, why are you conflating the spectators with the quarterback when jrs explicitly distinguished the two?

          2. Lambert Strether Post author

            Dan, we’ve had this discussion before, where I provided links to Republicans — not the Koch Brothers — who support single payer. I’m not going to waste my time digging them out again because you’ve shown you are not open to evidence on the issue.

            Adding, “obsessed” is cute. Nobody forced you to read the post, though — I assume this time you read all the way through?– so who’s obsessed, eh? It’s a big Internet. If you don’t like what you read, you’re free to go.

    3. Propertius

      Their entire strategy was based on convincing people that the ACA would be worse than both the existing system,

      And, of course, Obamacare is pretty much the old system, with the added feature of government compulsion and therefore a government-guaranteed income stream to the insurance companies. Any added costs due to actuarial factors will be compensated for by reducing coverage and increasing premiums in the out years. What’s not to like?

      1. Propertius

        And with, of course, the added feature of giving the insurance companies a pipeline into the public purse through the premium subsidy. How could I have forgotten?

        At that point, the legalization of age discrimination in group plan premiums is just icing on the cake.

    4. ian

      “Any movement toward single payer is going to have to come almost entirely from the left.”

      Movement towards single payer will only happen if the ACA turns out to be a disaster. If/when that happens, a logical question would be whether you would trust the folks that brought you the ACA to do another large scale makeover of healthcare.

      There is a third (IMO most likely) option besides keeping the ACA, or replacing it with single payer – modifying the ACA to death in piecemeal fashion.

        1. ian

          I most certainly do consider it a disaster. I should have been clearer – “widely perceived to be a disaster” perhaps.

  4. LAS

    I should like for us to move on to talk about some other interesting aspects of the ACA – which will have huge social repercussions. For instance,
    (1) so many more people will now be covered for mental health treatment and substance abuse treatment than ever before. This could be a direct benefit to younger adults.
    (2) There are also a lot of new quality control mandates in the bill that should improve the rate of hospital acquired injury and infection … accountability in care.
    (3) There are measures in ACA to expand the primary care workforce; but are these measures being adequately funded?
    (4) What will happen to hospitals and medical centers in hold-out states as the old Disproportionate Share Reimbursements are cut back? That money is now being re-directed toward Medicaid reform and states that have refused Medicaid reform are about to deprive their hospitals/medical centers of billions in funds and possibly drive them to financial ruin.
    The ACA is not just about insurance. It has a lot of provisions and its success depends on the integration of many ideas. It is much more a piece of legislative work than the general public has any idea yet.

    1. NotTimothyGeithner

      Since these ideas were discussed ad nauseum in 2007 and 2008, how are these ideas going to enter the public consciousness when they already exist? ACA isn’t a step to raising awareness.

      I’m going to explain it very simply. For-profit monopolies never work even when the democratic president calls it uniquely american. The sins of the existing system will be transcribed to any program boasting to radically change the system which fails to deliver promised goods. A democratic president and commanding congressional majorities failed to deliver and we’re contemptuous of anyone who warned them right wing kowtowing or complicity would comeback to haunt them.

      Everyone who reads this blog isn’t going to be convinced by vague promises about future success. Why don’t you try going to democratic voting areas with low turnout in off year elections instead of sitting at the DNC wondering why Obama is unpopular? You might actually increase turnout. The reason you don’t is you don’t really believe the crap you wrote, and Lambert’s articles about the predictable failures of ACA to reform the system underscore that your political participation is shallow and in many ways no different than Palin fanatics who vote out of ignorance and cults of personality.

      1. Propertius

        Ad nauseam.

        First declension.

        And if you don’t know what “first declension” means, Latin expressions are probably not for you.

  5. NotTimothyGeithner

    But…but President McCain would be trying to start a war with Russia…hmmm.

  6. AndyB

    The elephant in the ACA room will be wait times and access to doctors; far more significant than the Massachusetts experience which saw wait times for primary care physicians virtually triple. The AMA estimates that we are in a current shortage for these doctors to the tune of 200,000.

    1. NotTimothyGeithner

      There will be lots of problems. The real elephant will always be perception versus reality, and when I was a Democrat, volunteers and even campaign workers themselves would say ludicrous stuff. A major issue behind ACA’s decline in popularity isn’t GOP attacks but the difference between experience and what people at local Obama offices said in 2012.

      Maybe the Dims have figured this out which is part of the reason for moving goal posts of what ACA is because ACA is at best minor improvements to a hideous, rapacious system while not anything about HMO costs by not removing for-profit monopolies, increasing the supply of medical personal, or reducing sugar in our diets. Michelle’s get moving campaign would be more credible if she focused her popularity on addressing corn subsidies when we could easily pay farmers to grow healthier and less labor/resource intensive crops which can be made into non-sugar alternative products.

      1. TheCatSaid

        addressing corn subsidies when we could easily pay farmers to grow healthier and less labor/resource intensive crops which can be made into non-sugar alternative products

        Yes. And support for Allan Savory’s Holistic Management approach for livestock rearing that reverse desertification and combat climate change.

    2. Lambert Strether Post author

      AndyB, got a link on the Mass wait times?

      Pretty funny, actually. You make it over the narrow network hurdle, make it over the co-pays and deductible hurdle, and then have to wait forever in the office for your ten minutes with a doctor who can’t make medical decisions because the insurance companies do that now. Because markets.

      1. fresno dan

        I like to see some evidence that people get to talk to a doctor for 10 minutes….

  7. John Yard

    As of yesterday, something like 13% of registered voters considered the ACA a success. Leaving aside the polemics about the measure itself, and taking into account that the ACA is 4 years plus into gestation, it does appear the administration and the Democratic party has laid an enormous egg. After the truth about Watergate emerged, Richard Nixon had higher approval numbers. If I am wrong, I’ll be pleased to be wrong.
    I am not saying this in celebration. A Republican party dominated Senate is a real possibility – a direct consequence of the ACA, just as the loss of the House to the Repubs was clearly ACA related.
    Yet the party seems unmoved. I emailed a friend who is close to the party apparatus who is pushing an individual for the State Senate ( CA ). His comment to stats about falling real wages in the US, Japan, and Europe was ‘troubling, but so what ?’.
    I guess it is hard to care about an organization that, not in public, but privately, doesn’t seem too concerned about the welfare of the masses ( the individual I emailed was an environmentalist ).
    When they ask me for my money and time, lest there be a Repub Senate, in the back of my mind, I hear a voice saying ‘troubling, but so what ?’.

    1. Lambert Strether Post author

      “[T]roubling, but so what?” But the Democrat was troubled; they had feelings, and they shared them with you. Try that with a Republican! C’mon, let’s be reasonable, here.

  8. vedwin

    I really do enjoy this site and as a person looking at Obamacare from the left I see lots of things I don’t like both in terms of policy and implemenation. However, a lot of the commentary I see here seems to be of the opinion that all the people that do benefit from this very imperfect law would be much better of under a perfect law that had no chance of passing through a legislature that is rabidly against all things Obama.

    I don’t like the insurance company bonanza anymore than anyone else but we still live in a country where way too many people still view health care as a earned privilage rather than a human right (at least for people other than themselves). I think that the access to health care that way more people are going to have may change the political economics and fortunes for single-payer in the future.

    1. NotTimothyGeithner

      Oh, perhaps you are young, but in 2009 and 2010 Democrats had significant majorities when ACA was passed despite significant liberal criticism. You may remember MSNBC host Melissa Jones Perry and others denouncing liberal/lefty critics as racists and unicorn chasers while simultaneously making a burden promises about ACA that failed to materialize.

      If you aren’t young, why do you think posting clap trap is going to help Team Blue? Don’t you think the DNC and OFA would do better to reach out to low info voters who get their news from 630 network news if at all or supporting and advocating for positive fixes instead I found saying “it’s hard, so give up and enjoy crummy speeches”? When the Democrats shed the deadweight in the leadership, shut down OFA, restore the 50 state strategy, announce the Iraq War and financial crimes inquiry, demand Holder be fired not resign, and propose environmental policies to fit the crisis, then you might have a point, but right now, Democrats are nothing but whiny little selfish shits who think they are living non sorkin penned west wing reruns.

      Why do you think the Democrats held major hearings investigating the sanctity of baseball players and drug use instead of the Iraq War build up? Personally, the Benghazi witch hunt couldn’t happen to nicer people, and considering the immorality and insanity of our Libya intervention, annoying Hillary Clinton is better than the platitudes Democrats would heap on her if they weren’t being reminded Libya turned into lawless hellhole.

    2. hunkerdown

      No, what we are saying is, among other things, that the embarrassingly large and largely ignored number of people who do NOT benefit one bit from this law would be much better off under a law that treats improved health outcomes as a goal, rather than as a hopeful concession meant to legitimize and cement the economic and social position of a class of parasite.

      But you are absolutely right that the Western notion of a “just world” is perverse, sadistic and corrupt. American Exceptionalists in particular do seem to actively delight in spending twice as much time and fortune on creating and excluding scapegoats as they would on serving them. I mean, human sacrifice is stinky and icky and uncivilized but they need that orphan blood to power their gadgets…

    3. Banger

      The ACA was meant to create a public/private partnership how it ends up remains to be seen. One thing it does do is to make health-care more hierarchical and more political and may force things on the public they may not want. One of the advantages of the prior system was that alternative health-care was a real altnernative. If I chose to forgo the American heroic medicine Big Pharma oriented health-care and seek more effective and cheaper alternatives would not be forced, by law, to buy over-priced health-insurance. As it is everyone has to participate in the current model by law–I believe it is coercive and believe the Republican’s arguments were unfairly dismissed because most RP critics are mean-spirited and insane by any standard so no real debate on any aspect of health-reform was even possible and is still not possible.

      1. LucyLulu

        If the Republican arguments got dismissed, and I would disagree that they were, it was because they had politicians going on about death panels, socialized medicine, cuts in Medicare (benefits), and paraded around people who allegedly had lost their current coverage and seen their premiums skyrocket, later found to have been reported in error. None that I heard talked about the need to rein in health costs (as opposed to government’s share) or improve health outcomes or any other important issues.

        Almost ALL politicians are feckless pieces of corporatist shit. It’s a requirement to get elected. Our elected judges too. In NC, the Supreme Court justices heaviest donations come from the corporations whose cases are heard in their court, with totals in the $1 million range. How much of this amount is donations from civic-minded citizens with no special financial interests? We have a crony capitalism fueled by wealth concentrated in too few hands. We need tax reform to address the wealth inequality at the root of political corruption. We need to fix the wealth inequality to get rid of the corruption preventing tax reform. What to do?

        I’ve decided my positions are more often aligned with the interests of the entities that buy Democrats. Complaining about what should have been passed in 2010 doesn’t change that the ACA was passed and in place. It won’t be repealed which leaves the option of fixing it. That can be done, including states receiving funding to transition to single-payer, like NH. I predict the big changes will be seen in the states, with the successful programs adopted more widely. IIRC, Canada’s current health system was initially implemented by a single province.

        1. TheCatSaid

          Good point that changes may well come at the state level. Maybe that’s where the most effort should be (e.g., to get more states to follow the NH example).

    4. Oregoncharles

      “had no chance of passing through a legislature that is rabidly against all things Obama.” – Classic propaganda doublespeak. No, it had no chance of passing through a legislature totally controlled by Democrats, who were riding high on a huge voter endorsement.

      In other words, it didn’t pass because it wasn’t even considered – it was ruthlessly kept out of consideration – BY THE DEMOCRATS, because they’re ruthlessly against it, as they continue to make clear.

      And that’s just one reason some (a lot?) of us aren’t Democrats any more. Just look at the politics: imagine that single payer HAD been passed; it would have been implemented by the election in 2010, which the Democrats lost big; by now, it would be as established and as popular as Social Security or Medicare. The Republicans would be a minor party. There would certainly be no discussion of the Dems losing the Senate this year, as they probably will.

  9. vedwin

    Well I’m not too young and I’m not too old. I do recall the political wrangling it took to get spineless “Blue Dog” Dems on board with the bill which went on long enough for Ted 60th vote Kennedy to die. Are we meant to believe that they would have endorsed single payer instead?

    If you want to berate most Dems for being feckless corporatist pieces of shit then I’m with you. If you want start the revolution that brings about that list of demands then I’ll sharpen my pitchfork. I agree that the party needs to be held accountable by its left flank but some of the comments I read hear are almost tea-partyesque in their frothy disdain for the ACA. I honestly can’t tell if the consensus here is that no changes to the state of health care in the US would be better than the changes we got.

    Let’s just not forget that real live people are in fact benefiting from this law whether it meets your test for ideological purity or not.

    1. Lambert Strether Post author

      If the administration, the Democrats, and the so-called “public option” crowd were acting in good faith, they would have given single payer advocates a seat at the table, even if they didn’t adopt the policy. We would then be in a far better position to advocate for single payer as the next step beyond ObamaCare. But they did not act in good faith: They silenced, censored, and suppressed single payer advocates at every turn. It looks like they’re trying to make ObamaCare a ceiling instead of a floor, the final word instead of the first word. Pretty appalling, when you realize they’re signing on to 24,000 excesss death a year.

      1. vedwin

        You don’t have to convince me about single payer and the abomination that was the negotiating process (farce) for the ACA. However I disagree about ObamaCare being the ceiling. People are going to like being able to seek medical care without being financially ruined. People are soon going to expect coverage despite pre-existing conditions as a right. These were impossible features in the previous health care situation.

        Perhaps optimistically this tells me that this law is going to be improved as time goes on rather than be disassembled. As the republicans have rightly feared, now that people have access to healthcare there is no going back. When public spending on healthcare reaches the tipping point rather than just the old and the poor that would have be affected it will be a broad cross-section of Americans and I suspect that there will be far more motivation to start using the purchasing power of the state to lower prices or to move to single-payer.

        1. Lambert Strether Post author

          I didn’t say ObamaCare will be a ceiling; I said the Democrats were trying to make it one. I don’t think they’ll succeed. I’m certainly doing what I can do to ensure they fail.

        2. Oregoncharles

          “Perhaps optimistically this tells me that this law is going to be improved as time goes on rather than be disassembled.”
          Yes, VERY optimistically, because the Democrats’ fecklessness has handed control over to the Republicans, who have even less interest in “improving” the ACA. Remember, even beyond Congress, the pattern for the last 20 odd years is that the major parties trade the Presidency back and forth, two full terms at a time. Obama’s poll ratings are still very low. Which party do you think will get the Presidency in 2 years? AND control of Congress?

    2. jrs

      Is real people benefitting a short term or a long term proposition. Real people may be benefitting now (and yes that is real) but if health care costs keep rising, I suspect there will be a lot fewer people benfitting soon (and no enforcement now of the employer mandate and employer plans getting more expensive every year so that soon everything will be “cadillac” and no limit on how much the individual mandate penalty can be increased or how much the subsidies can be cut or just fail to keep up with inflation. Don’t think subsidies can be cut? Why not? Everything else is a candidate for cuts).

    3. Alexa

      Some may have that test–I don’t.

      It does depend on “whose Ox is gored.”

      Many tens and tens of millions of Americans MAY BE adversely affected by the ACA.

      We have been.

      Our premiums and out-of-pocket costs have skyrocketed since the ink dried on the ACA in 2010. (Our group healthcare premiums had risen modestly for a 3-4 years, but our out-of-pocket costs remained static–until the ACA became law.)

      Our employer “blames this” on two major mandates: (from their standpoint–they always included “mental health” coverage in their offerings) (1) mandatory coverage of “children” under age 26 on parents plans, (2) and mandatory maternity benefit.

      Company says that maternity care costs recently have come to exceed “end of life” costs–partially driven up by skyrocketing numbers of Cesarean sections. And, this topic was covered on C-Span, about a year ago.

      The result? We now have “catastrophic” group health coverage, as opposed to what was once an excellent group health plan.

      IIRC, I read that there are over 100 million Americans covered by group health plans.

      Dems could be looking at serious electoral difficulties in the years to come, if this should become widespread. (And I don’t pretend to know if it will.)

      1. Pat

        Two points regarding the mandatory maternity benefit.
        1.) Yes, private hospitals have been milking the cost benefits of cesareans versus natural child birth. And yes, the costs of maternity have been rising in a manner not supported by the actual costs involved. I’m not sure why it has become a cash cow for this industry but it has.
        2.) The addition mandatory maternity was always a given. All for cosmetic reasons, well not quite it is a cash cow, but mostly cosmetic. Now do not get me wrong – maternity (not fertility) but maternity and infant care should always have been a part of all health insurance except catastrophic coverage. That said, one of the big points of embarrassment for the US has been the fact that Cuba has better rates of infant mortality then we do. Actually they have better rates on many health issues, but that infant mortality rate thing gets published whenever the sad standing of US health care makes the news because there is nothing partisan about infants. Can’t have Cuba beat us in anything.

        1. Oregoncharles

          And you really think that coverage will lower infant mortality? Much of infant/mother mortality is driven by EXCESS medical “care,” and has been for a long time. If they mandated midwives, as Cuba probably does, then you might expect some improvement.
          Pregnant women aren’t sick and don’t belong in hospitals unless they really do have a problem.

          1. Pat

            Where did I say it would work. I said it was there to do that, not that it would be effective.

            I have so little faith in either the goals of the people who wrote this law OR in its ability to do anything to better our health care results that even if it were the right way to do it, I’m pretty sure it would fail. (And that doesn’t address that nothing says that even though it is covered, the insured will be able to find a provider in their network.)

          2. LucyLulu

            I won’t argue that US women get too many C-Sections, assuming that’s what you mean by excess care. Not all women want midwives and the “natural” childbirth option. It can be excruciatingly painful or it can be more along the lines of very uncomfortable, more often closer to the former. After two labors, both posterior and requiring oxytocin ultimately, the first lasting 24 hours, the second 18 hours, I would skip another child before considering “natural” childbirth. Sure, women did it that way for thousands of years. They also went without painkillers for broken legs, evisceration by wild animals, etc. We wouldn’t make anybody do that now.

            I’d like to know where there is data supporting that excess care is a significant driver of infant mortality. I would think it was driven by lack of prenatal care and nutrition, and sometimes plain ignorance. And the primary driver of excess Caesareans is fear of malpractice. If a baby is born and isn’t perfect, and the OB didn’t pull out all the stops, they are likely to get sued. That’s why so many OB/GYN’s are now only GYN’s (or due to cost of malpractice). The hospitals may well piggyback off this and pad the bill to take a generous cut. They often do.

    4. Pat

      Please explain to me the need to pass a law written by the Heritage Foundation and updated by an Aetna lobbyist. Especially since the major components that people either like or approve of were possible piecemeal. Yes, the government could have expanded medicaid. Yes, the government could have mandated that people be allowed to keep their children on their policies until age 26. Yes, the government could have mandated that insurance companies provide insurance for those who are already ill.

      Now explain to me why the leaders didn’t twist arms on those weakening the law, only on those fighting them. And why when the two bills went into reconcilliation, the place which meant they could drop all pretense of needing 60 votes, they pieced together the weakest NOT the strongest bill to protect consumers of this not legally mandated product. And why when designing or setting up standards not outlined in the bill HHS chose to overwhelmingly weaken even the position of the people and strengthen that of the private corporation?

      The “we couldn’t get anything better” was a lie from the outset. And anyone who accepts it is being grifted as surely as the people who buy the Koch brothers bullshit are.

      1. Oregoncharles

        Could you please document the part about reconciliation avoiding the filibuster? I’ve been involved in an argument about that, and lost because Wikipedia. I’ll check back – could really use some links on that issue. I remember it the way you describe it, but Wikipedia doesn’t. You seem to be better sourced on this than I am.

        1. LucyLulu

          I remember too. Ultimately it was passed using a simple majority under reconciliation. No Republicans voted for it. Not sure if all Dems did.

          1. Lambert Strether Post author

            In other words, at the end game, the filibuster was irrelevant (as are the excuses of Obama apologists who claim that was why we couldn’t get a better bill). The law we have is the law the Democrats wanted, period.

  10. Doris

    The disaster in Massachusetts continues. It was announced in the last two weeks that the state website, HealthConnector, will be scrapped. It couldn’t even spell “shopping” correctly. Starting now two tracks will be pursued: one to merge with the federal website in case the other, a $56M “off the shelf” software package, isn’t working by 11/15/14. They have failed at doing one thing over the last several years and will now try to do two things in six months. The company paid to assess the situation, Optum, is, surprise surprise, 24% owner of hCentive, the “off the shelf” provider. At least when we had the Romney corporatist extraction operation, the damn website worked! It’s time to admit that this whole thing is corrupt and only meant to transfer funds from the CITIZENS, NOT “CONSUMERS”, to the IT companies.

    1. Oregoncharles

      Isn’t Massachusetts one of those high-tech states, as well as super-duper blue?

      Of course, so is Oregon, which also couldn’t make a website work.

      1. Doris

        Why yes it sure the heck is! Maybe someone wants Mass. to stop being all smug about that snooty education and stuff.

  11. B. Lyman

    This is the first time I’ve been to this website. I just want to tell all of you commenters “thank you” for being (mostly) civil in your replies. You debate policy and ideological differences in such a way that a person on the opposite side can understand why you believe the way you do.

    If you want to see the opposite read the comments section after any political article in the Washington Post about the ACA or Obama. The comments can be very nasty and vile (and some boards will have over 6,000 comments). I get so sick and tired of reading the pejoratives “mittens” (for Romney), “wing nuts,” tea—” (I never write out the full name anymore since finding out what it means),” Obummer, Moochelle, etc. The stereotyping of both the democratic and republican party by each others’ is especially tiresome. (“You hate the poor and want them all to starve”; “All teapartiers are racists;” “You liberal low info welfare leeches” (to paraphrase).

    Your intelligent commentary is very, very refreshing. I wish all comment boards were like this one.

    1. Yves Smith

      Yes, thank you!

      Lambert and I do intervene to enforce house rules to try to insure a level of civility while keeping the comments section as open as possible. It seems over time to have worked, in that commentors who want to engage in thoughtful discussions persist, and the ones who are more interested in cheap shots and vitriol either are met with sound and more articulate rebuttals by the commentariat, or with persistent trolls, are given the heave-ho by the site admins.

    2. Oregoncharles

      Actually, in my experience “Obummer” is a left-wing pejorative, but I agree it’s distasteful.
      “Obomber” is pretty to-the-point, though.

      I agree that NC has an unusually useful and civil comments section. Which is not to rule out passionate.

  12. Alexa

    Alexander is pretty much the “mirror image” of a centrist Democrat, as is Bob Corker.

    And he and many Republicans “adore” Sylvia Burwell.

    Read recently that a “saying” in Washington Elite Circles, by both parties, is: Where’s a Sylvia, when you need one? (paraphrasing)

    Some Democrats are already on record supporting the repeal of the “employer mandate.” IMO, the public will continue to oppose the “individual mandate”–especially, if Dems nix the employer mandate (which I am convinced that they will do–if not before, after the 2016 election).

    BTW, there are numerous articles talking about “compromise” on ACA reform. Most of the faux attempts to repeal the ACA were “Kabuki”–to mollify the Repubs’ conservative base.

    I agree–both parties will do ANYTHING to avoid enacting a single-payer healthcare system.

    Including compromise–at least “after” the 2016 Presidential Election.


  13. different clue

    So some Democrats support the Rs in making Ocare more purely Heritage. What are their names?
    I wonder if Obama was their secret agent right from the start.

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