ObamaCare Roundup: Constitutional Challenges, Profits, Medicaid, and Costs

By Lambert Strether of Corrente.

It’s been awhile since I’ve posted on ObamaCare, and this survey is an attempt to pick up the threads; I’m afraid I’m selecting for coherent narrative rather than the questions I’d really like to ask, like: How are narrow networks, including hospitals, doctors, and formularies, affecting the quality of care? Are ACOs really just HMOs in disguise? Is the back-end fixed, and are the 834s finally working? Are we ever going to get really accurate enrollment figures from the ObamaCare hub database, or are we going to keep relying on Gallup? What’s going to happen to employer insurance? And will anybody ever be held accountable for the website rollout debacle? I’m guessing no on that one, and I’m sure readers can come up with some answers, some new questions, and even ask and answer their own questions!

Will ObamaCare pass Constitutional muster again?

The latest Constitutional challenge comes from the conservative side of the aisle, given that the Democrats only raise “rule of law” questions when their guy isn’t President. The point at issue: The Supreme Court decided that ObamaCare was constitutional because the mandate was a tax. But in Civics 101, we learned that revenue bills must originate in the House, and a tax raises revenue. And — at least substantively — ObamaCare did not originate in the House:

At issue, again, is the individual mandate, requiring most Americans to buy health insurance or pay a government fee. In 2012, a five-member majority of the Supreme Court labeled the individual mandate a “tax.”

What they didn’t answer was whether this “tax” was created in a valid way.

That’s the question posed by the Origination Clause lawsuits — one from small-business owner Matt Sissel of Washington state, the other from Steven Hotze, a physician from Houston, Texas.

As both lawsuits point out, the Founders wanted taxes to start in the House because it is the chamber most accountable to the people.

But Obamacare started in the Senate. Majority Leader Harry Reid erased the contents of an unrelated House bill (the “Service Members Home Ownership Tax Act of 2009”) and replaced it [with] the Patient Protection and Affordable Care Act — Obamacare.

Hotze’s lawsuit, which is at the Fifth U.S. Circuit Court of Appeals, has yet to be heard. But oral argument in Sissel’s case was held in early May at the U.S. Circuit Court of Appeals for the D.C. Circuit.

The questioning was tough, underscoring the contentiousness of the issues. For instance, it was suggested that the individual mandate is meant to prod people to buy insurance, not raise revenue. However, the Supreme Court didn’t attach any qualifiers when it labeled it a “tax.”

So the issue is whether what Reid’s procedure violated Article I, section 7. Maybe so, probably not:

As for the merits of the claim, what makes the Origination Clause argument difficult is that Congress observed the Origination Clause in form if not in substance.  The Senate took a bill that had passed the House, stripped out its contents, and inserted the PPACA so that it could claim fealty to the Constitutional requirement.  This approach clearly circumvents the purpose of the rule.  So, would a Court throw out portions of the PPACA on such grounds?  I doubt it.  Although the Supreme Court has suggested its willingness to consider such arguments before, I am skeptical that federal courts are likely to scrutinize how legislation gets produced.  Thus, for example, the D.C. Circuit has turned away challenges to federal legislation that allegedly violated the enrolled bill rule, refusing to second-guess the legislature’s certification that a given bill satisfied the relevant constitutional requirements.  When a federal court reaches the merits of an Origination Clause challenge, I would expect a similar outcome, even if this means the Senate may continue to play fast and loose with the origination requirement.  Utilizing shell bills may make a mockery of the rule, but it’s not the sort of thing that is likely to be overturned in federal court.

So, a story to watch, if only because the very word “taxes” causes so many knees to jerk.

Profits

Because markets, I don’t know why there’s such a focus on enrollment numbers; surely the more relevant metrics are profits and stock prices? I don’t normally quote The Motley Fool, but since stock touting is the whole point here:

Why the Obamacare Profit Surge Isn’t Over Yet

One of the crucial areas where the Affordable Care Act, better known as Obamacare, has driven profitability for insurers has been through the expansion of Medicaid, which the majority of states have implemented. Those millions of new people on the company rolls have helped drive revenue across the industry. And more may be yet to come.

Yes, we think of Medicaid as a government program, but when we increase funding for it, we’re really increasing pass-through to private contractor. It’s enough to make you go all NHS! Sorry for the stock picking, but here are some numbers:

Insurers Molina Healthcare (NYSE: MOH ) , UnitedHealth (NYSE: UNH ) , and Aetna’s (NYSE: AET ) Coventry Health may all see sales growth tied to the Affordable Care Act’s Medicaid expansion this year as California digests a big backlog of enrollees and Michigan’s newly launched expansion kicks in.

Molina is a major provider of Medicaid services in California, and all three companies provide private Medicaid insurance in Michigan, where the enrollment expansion began on April 1.

California already accounts for more than 20% of Molina’s Medicaid members, and the expansion is already contributing significantly to company sales this year. In the first quarter, Molina’s revenue soared 21% to $2.1 billion — thanks in no small part to California enrollees, who accounted for 47,000 of Molina’s 133,000 new Medicaid members.

And the profits goose stock prices:

In the 12 months ended April 30, health-care stocks in the S&P 500 index gained 22.7%, beating the overall index’s 17.93% return. Health-care stocks made up 13.2% of the S&P 500 index’s market capitalization as of April 30.

Mission accomplished! But let’s recall:

The key point to remember in all discussions of ObamaCare is that neither it, nor indeed the entire private health insurance “industry,” should exist. They are rent-seeking parasites, economic tapeworms. One does not improve a tapeworm; one removes it.

To understand this simple point, all we need to do is look north to Canada, where we see a single payer system — they call it “Medicare” — delivering equal or better health outcomes at dramatically lower cost, without a health insurance industry, and without ObamaCare’s bizarre, mystifying, and above all unfair Rube Goldberg-esque complexity. In fact, if we’d passed HR 676 in 2009, we would have saved hundreds of billions of dollars by now (more than enough to cover everyone) and thousands of lives, though ObamaCare apologists don’t like to talk much about the excess deaths that ObamaCare’s achingly slow rollout caused and is still causing.

So, profits there may be. They have at best no social utility; they do not serve public purpose. It’s as if we were diagnosing the health of a body by measuring he length of a tapeworm within it.

Medicaid

Below — and check me, readers, this part has numbers — we see 1.7 million applicants in limbo + 2 million accounts with “discrepancies” = 3.7 million, and 3.2 million / 8 million = 46% of 2014’s ObamaCare surge have screwed up Medicaid accounts. Of course, the Republicans can’t hold hearings on this, let alone run a Dukakis-style “competence” campaign because (a) even they couldn’t handle the hypocrisy of denying Medicaid to their own citizens while alos exposing how poorly the administration handled expanding it, and (b) they would rather wank about repeal anyhow, to throw red meat to their base and because markets (see Profits, supra). Anyhow, ObamaCare’s their plan.

1.7 Million Applicants in Limbo

Kaiser Health News:

While an unprecedented 6 million people have gained Medicaid coverage since September, mostly as a result of the Affordable Care Act, more than 1.7 million more are still waiting for their applications to be processed—with some stuck in limbo for as long as eight months, according to officials in 15 large states. Federal and state officials say the delays should not hamper people’s ability to get health care because Medicaid coverage can be extended retroactively for three months and people can seek emergency care at hospitals.

“Can be extended retroactively…” What could go wrong? And ER rooms are over-extended as it is. Anyhow, this could go wrong:

But [Stan Dorn, senior fellow with the nonpartisan Urban Institute] said that some providers may refuse to see patients until they have confirmation they have insurance coverage. And without insurance, patients may not have cash to pay doctors who demand it upfront.

The waits also contradict the administration’s promise that the online insurance marketplaces would bring a “no wrong door” approach to signing up for health care, regardless of a person’s income.

Wait, what? The administration lied again?

[T]he process has been further complicated by state eligibility reviews that have found many people ineligible who applied through the federal marketplace. States were always expected to make final eligibility decisions, but that has taken longer in some places than anticipated.

Of the 245,000 Ohioans who applied through healthcare.gov, for example, 93,000 were found ineligible, said state Medicaid spokesman Sam Rossi.

Another 66,000 had already enrolled or are in process of enrolling directly through the state Medicaid program. Ohio, which expanded Medicaid eligibility, has more than 65,000 cases pending, he said.

Yikes!

2 Million Have ‘Discrepancies’

Yes, with 21 separate items to fill out on the ObamaCare form, all of which are crosschecked against data from the IRS, DHS, CMS, the Bureau of Indian Affairs, and credit reporting agencies, not to mention whatever’s going on at the state level, it’s turned out there are some mistakes. (How, or whether, the mistakes will affect people’s health are is not known.) From the LA Times:

More than 2 million people who got health insurance under the Affordable Care Act law have data discrepancies that could jeopardize coverage for some, a government document shows.

About 1 in 4 people [that seems like a lot to me] who signed up have discrepancies, creating a huge paperwork jam for the feds and exposing some consumers to repayment demands, or possibly even loss of coverage, if they got too generous a subsidy. Updated numbers provided by Bataille indicate that the total number of people affected remains about the same as a month ago. About 1.2 million have discrepancies related to income; 505,000 have issues with immigration data, and 461,000 have conflicts related to citizenship information.

(At this point, we recall that people filled out their ObamaCare forms under penalty of perjury.)

CMS says that the “discrepancies” shouldn’t affect coverage. Politico:

The officials emphasized that discrepancies in people’s application data are unlikely to affect their coverage or the level of subsidies they received. Rather, they’ll have to submit additional documentation to ensure that they’re getting the correct level of tax credits.

The result: some Americans may have received greater subsidies than merited or were allowed to purchase plans for which they were ineligible. HHS says it’s now “double- and triple-checking” with applicants to verify their information.

Wait, which is it? “Unlikely to affect their coverage,” or “allowed to purchase plans for which they were ineligible”? (I wonder if many of these people were “on the bubble” between being forced in to Medicaid, or allowed to buy a plan on the Exchanges.)

Where a consumer fails to provide the follow-up information, or reveals that they have erred, the policy will be revoked and a request for subsidy repayment will be made, [HHS’s Julie] Bataille said.

What could go wrong? This sounds like people being told to skip payments to gain eligibilty for HAMP.

She said the agency is scrambling to follow up with each applicant, commonly requesting copies of paystubs as proof of income or birth certificates to verify the correct spelling of a name.

System D people — remember how nail salons are a bright spot in the economy? — don’t need no stinkin’ paystubs.

Except the discrepancies will affect coverage:

Responding to the document, administration officials expressed confidence that most of the discrepancies can be resolved in the next few months. Nonetheless, the department has set up a system to “turn off” benefits for anyone who is found to be ineligible.

So, the discrepancies are unlikely to affect coverage except they will. Too bad we can’t just have citizens covered because they’re citizens under single payer. Then maybe all the government officials setting up these programs and explaining them to the press could be doing something valuable with their time.

The Asset Recovery Program

There’s a ray of hope on the Medicaid Asset Recovey Program, at least in California. Here’s an explainer with the state of play:

Obamacare wrinkle: California bill seeks to reduce state’s seizure of Medi-Cal recipients’ assets

One of the Medi-Cal recipients is Campbell resident Anne-Louise Vernon, 59. She contends that California’s aggressive cost-recovery program is unjust because people whose higher income levels allow them to get subsidized private health insurance through the new Obamacare health care exchanges don’t have to pay back anything.

I’m glad to see somebody make the “justice” case; since the insurance, and hence ultimately the care, if any, that citizens receive from ObamaCare varies so randomly by age, income, jurisdiction, and employment status, among other things, there’s hardly any aspect of the program at all that can be said to be “just,” if by justice we mean equal treatment for citizens, before the law. It’s wrong to mandate that people purchase a product, and then have the degree to which the product is defective depend on “the luck of the draw.”

Vernon said she requires constant medical care because of severe nerve damage in her arms and arthritis in her legs –conditions that have prevented her from finding a job. The divorced mother of two said her home is her only real asset.

Medi-Cal, she said, has now essentially imposed a “reverse mortgage” on her home in exchange for health insurance.

“What is fair about that?” asked Vernon. On Tuesday, a state Assembly health committee will take up proposed legislation that would limit Medi-Cal recovery only to what’s required under federal law: the cost of long-term care in nursing homes.

Authored by state Sen. Ed Hernandez, D-West Covina, SB 1124 has already sailed through two Senate committees.

Should it pass Tuesday and then get the blessing of the Assembly appropriations committee in mid-August, it would be voted on by the Legislature by the end of August. Brown would have until the end of September to decide whether to sign it.

“I don’t know of any other program that demands repayment after a recipient dies,” said Hernandez, who chairs the Senate’s health committee. “We don’t do it for Medicare. We don’t do it for people getting coverage through the (Covered California health care) exchange, and most other states don’t require estate recovery. People are really frightened about this policy.”

Costs

Sarah Kliff has a good article on “Selling ObamaCare” in Vox. I’m going to excerpt one woman’s story to show what Kliff missed:

[Celia] Maluf was optimistic about the health care law when it passed in 2010; she hoped it would lower her premiums to about $200, an amount she thought she could fit into her budget. Instead, the insurance plan would cost $359 after a subsidy. It was much less than the premiums she saw in the past, but nearly double what she’d hoped to pay.

Maluf didn’t expect to have high medical bills; she’s the type of person who gets one or two colds each year. In the nine years she spent without coverage, she never had a major illness.

“I went back and forth and back and forth, on what I should do,” she says. “The whole October and November and December, I was going back and forth. On Christmas Eve, I made my decision.”

Maluf ultimately decided, after three months of deliberation, to purchase an insurance plan. That meant trade-offs: she’s skipping a trip to Brazil to visit her baby niece, and putting off building a website to advertise her pilates business.

“It’s been very challenging,” Maluf says. “I haven’t been able to travel much. I really don’t have any money left to spare now.”

Maluf says she does want to buy her health plan, which she hasn’t used yet, again next year. But she’s not totally sure she will be able to afford it anymore. The rent on both her apartment and her pilates studio increased by more than $200, which has further squeezed her budget. She thinks her income this year, which she earns at individual pilates lessons and therapy sessions, will be lower than she had initially expected.

“I am at the maximum,” says Maluf of what she currently pays for health coverage. “I couldn’t go higher than this, not by a penny.”

So — and this is the conclusion Kliff does not draw — the opportunity cost for Maluf for purchasing ObamaCare was marketing her business (plus travel; people need and deserve time off). And it’s at least a tenable theory that because Maluf couldn’t market her business, her business won’t bring in as much as it should have, and not enough to buy insurance again if the cost of ObamaCare goes up at all, which it’s likely to do. And people wonder why ObamaCare polls badly! Feed that tapeworm, baby! (And note the conservative case for single payer here; it encourages entrepreneurs!)

* * *

Well, that’s a wrap for today. ObamaCare is the same tapeworm it’s always been!


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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.

29 comments

  1. John

    I am sure you read Wendall Potter’s latest piece on outsized Health Insurance CEOs salaries. Mr Potter has been a steadfast supporter of Obamascare. He was an insurance PR man in his previous job but saw the light, quit and raised concerns about the health insurance business model.

    However, Mr Potter sometimes delivers essays that skips over critical issues with Obamascare. In his latest piece he writes about how Health Insurance CEO salaries are exploding and Congress should take notice. What the article failed to articulate is the connection between salary increases and the burgeoning windfall Obama handed to the industry. Wall Street always reward their CEOs handsomely when government hands them new revenue, everyone knows that.

    http://wendellpotter.com/2014/06/skyrocketing-salaries-for-health-insurance-ceos/

    1. Cynthia

      Believe it or not, the Affordable Care Act also increases opportunities for hospital administrators to earn more as well. That’s because the ACA encourages consolidation of physician practices under larger corporations, and those corporations are the ones that receive financial windfalls through government incentives. The physicians themselves become employees subject to decreasing reimbursement for their services, but the executives at the corporations continue to earn more. You can prove that by looking at the record surge in stock prices for health care corporations.

      In the end, Obama is delivering even greater profits for the corporate executive who donate to him, and he has put downward pressure on physician wages, which ultimately hurts patients.

    2. Benedict@Large

      Several things to keep in mind on CEO salaries. [1] They are high everywhere. This is not a problem specific to the health insurance industry. [2] CEO salaries in health insurance run about $1 per insured per year. They may be objectionable, but they do not drive healthcare costs. [3] As NC has pointed out in several articles recently, there’s a problem in general with extreme salaries going to top management in non-insurance healthcare providers and support. [4] And as John points out, salaries for top executives in any business the government is directing money towards are going to go up.

  2. DakotabornKansan

    “WL’s [White Liberals] think all the world’s problems can be fixed without any cost to themselves. We don’t believe that. There’s a lot to be said for sacrifice, remorse, even pity. It’s what separates us from roaches” – Paul Farmer, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World

    Our crisis in health care is much more pronounced for people with cancer due to the high costs of drugs, tests, and procedures.

    The costs of caring for my wife, who died from metastatic leiomyosarcoma thirteen years ago, were just under one million dollars.

    John Geyman, M.D. writes that cancer care is the Achilles heel of our profit-driven health care system “as costs and prices continue to escalate, access and affordability decline, and gaps in quality of care further widen. Care of cancer in this country is outpacing other health care problems and is already pricing itself beyond the reach of many Americans unfortunate enough to contract the disease.”

    “All this represents an ominous trend, standing out more starkly all the time compared to other advanced countries around the world, where comprehensive cancer care is available to everyone, typically with little or no cost-sharing and often with better outcomes. The Affordable Care Act (ACA) has not contained costs and prices, but instead has allowed insurers and the drug industry to continue to profiteer at patients’ expense.

    http://blog.hc-disconnects.com/2014/06/09/cancer-care-in-the-usachilles-heel-of-a-profit-driven-system.aspx

    “[Obamacare] was almost the perfect example of politics in the Bubble Era, where the time horizon for anyone with real power is always close to zero, long-term thinking is an alien concept, and even the most massive and ambitious undertakings are motivated entirely by short-term rewards. A radical reshaping of the entire economy, for two election cycles’ worth of campaign cash – that was what this bill meant. It sounds absurdly reductive to say so, but there’s no other explanation that makes any sense.” – Matt Taibbi, Griftopia: Bubble Machines, Vampire Squids, and the Long Con That Is Breaking America

    “I’ve been asked a lot for my view on American health care. Well, ‘it would be a good idea,’ to quote Gandhi.” – Paul Farmer

  3. Kmurp

    In upstate NY, I am not seeing any apparent difficulties is Medicaid enrollment. It’s exploding upwards around here. It’s generally run by non profit insurers though.
    I’m having trouble sympathizing with the lady who is spending money on health insurance instead of taking a trip to Brazil.
    Although I might be sympathetic to the poor lady in California who is losing her home equity, I wonder if her maladies are due to morbid obesity (knee arthritis and perhaps neuropathy?) is suspect she’s getting disability payments as well

    1. scraping_by

      Morbid obesity is a health problem related to modern living, not personal failings. It’s spreading to the rest of the world along with processed foods and other American innovations. My first thought was job-related repetitive motion injury cause by poorly designed work duties. And anyway, the prejudice against the undeserving sick is just an update of the prejudice against the undeserving poor.

      The choice between having a life and having health insurance is a false choice, but one that’s been created by the insurers and their government servants. Were she Canadian or European, she could have both and only mean-spirited busybodies would think twice.

      Sanctimony is a vice of cowards, but it’s also useful for divide and conquer.

      1. Kmurp

        This woman DOES have health insurance. At least according to the article, so she doesn’t need to move to Canada.

  4. Jim Haygood

    ‘Utilizing shell bills may make a mockery of the rule, but it’s not the sort of thing that is likely to be overturned in federal court.’

    Quite so. The function of a rubber-stamp judiciary is to manufacture a plausible rationale for why “it’s all legal.”

    Chief Injustice John Roberts already did that with his fantastical ‘it’s a tax, not a penalty’ subterfuge.

    Not that little people should get any clever ideas about using such transparent wheezes to subvert the clear intent of the constitution. Leave this to the experts, folks!

  5. Benedict@Large

    Re: 2 Million Have ‘Discrepancies’

    This is normal stuff for a systems installation of this sort. In fact, it would have been surprising had it not happened. Are there any serious problems here? Probably a few, but this is not likely to be anything much more than a clerical cleaning operation.

    1. scraping_by

      Transaction failures at this rate would doom any commercial enterprise. Rates far smaller have done so.

      The contractors involved must have some pretty sweet deals to let them deliver failure and get rewarded for success. Part of it is certainly preserving the optics, part of it is certainly indifference to the stated goal, but likely much of it is contracts without penalties. A form of subsidy, in the end.

      1. NotTimothyGeithner

        Yeah…but…ummm…LBJ didn’t have people out to destroy him like Saint Obama…remember how reasonable George Wallace* was?

        *Interestingly enough, Wallace became quite a bit more reasonable after LBJ ended negotiations, wished Wallace luck as the next Jeff Davis, and asked how he was going to stop 101st.

  6. mellon

    I watched the complete Senate Finance Commitee hearings in 2009 and I wish I had a nickel for each time the various drafters of the bill insisted that the exchange plans would not be “too attractive”, nor would they be available to many people. The concerns expressed were completely confusing to me then. I wish I had recorded the sessions. (Did anybody?)

    People have to understand, these ACA plans are deliberately horrible so that people with the ability to do so, will buy non ACA private insurance first. If they have any possible way to do so. But of course, a decent PPO plan for a family these days (the kind of insurance the poor really need, because it protects people from risk semi-adequately) is more than many Americans income. ($23,000 a year for a group plan, according to Milliman, probably twice that for a nongroup PPO plan, if past pricing is any guide. Probably even more in an urban area like NYC! Can anybody fill in that data?)

    The United States is aggressively against public healthcare in our trade policy, which is multilateral so there is zero chance that the ACA was going to actually be public, GATS would prohibit that.

    So, its private, potentially and dangerously irreversible, as soon as a multinational becomes involved, and in fact its intended to be where all the people in the terminating public programs end up so it has to superficially look better than it really is, to facilitate that transition, so that the thousands of ACA-astroturfers and to some extent, seven out of ten people who don’t have some kind of serious health condition will be able to drown out the complaints from the two or three in ten who are buried with bills they often can’t pay. Also, it tries to push the sick out of the healthcare system (or out of the work force- as Medicaid will be the only way they can get care they can afford- so they wont be able to work), with debt.

  7. mellon

    People who buy ACA “exchange” plans which use up most of their income wont have any money left for the co-pays, deductible, very high drug cost co-pays (50% of retail, which is almost certainly far more than the insurer pays the drug companies directly for the drugs- (something that government programs seem to soon not be allowed to do -really! because of clauses in our MULTILATERAL FTAs banning such cost-saving strategies!!)

    In other words, I would not be surprised if insurers were using this captive group to max out their profits in numerous areas.

    Also, people should be aware that ENERGY costs (heat, electricity, which are both driven by natural gas prices) may skyrocket in 2016-2017 (rise to global average levels, currently US natural gas prices are a fraction of the global norm) because of the potentially huge TTIP US-EU fracking export deal.

    So, people should budget for those additional costs- I’ts long been common sense, that people who don’t have enough income to actually pay the out of pocket cost max as well as the premiums (basically $6250 for a single person and $12500 for everybody else) should consider going without and instead put that money they are saving by buying cheap insurance into an HSA – (put away at least that OOP Max for a year or two) to cover those eventualities, otherwise they will be spending money for insurance they cannot use if they get sick and as soon as they miss a bill, and the out of pocket charges can be huge, they will no longer be insured.

    A recipe for disaster for poor people with a chronic illness.

  8. Doris

    Google healthcare.gov amazon cloud for articles about the latest plans for fixing it all up.

    1. mellon

      Doris,

      >“Google healthcare.gov amazon cloud for articles about the latest plans for fixing it all up.”

      The “two parties” dirty little secret is that it cannot be fixed up, they coordinated their strategy and lied about almost everything, to prevent people from realizing that, and its worked, even most of the liberal blogo sphere – including many friends, is still completely lost in their disinformation cloud trying to understand what’s going on through their completely wrong framing, and swallowing their further, expert-crafted memes. One would do better assuming that everything is backwards from what they say, that would actually be a better start than believing any of it.

      Basically, the for profit system has been unaffordable to most working Americans since the early 1990s, getting progressively more so since then.

      But they cannot admit that because there would only be one conclusion which would then avoid a charge of crimes against humantity and that is immediately shifting to single payer, and dumping the trade agreements, all of the ones which mandate no changes in laws for multinationals.

      all they can do is keep moving the deck chairs around on their Titanic and try to use the undemocratic free trade agreements to take any future “choice” off the table – so that no future uncorrupted Administration can reverse all the mischief they have done and attain affordable health care for America..

      They have devoted a huge amount of effort into weaving a web of deceit piece by piece to convince Americans that they could afford the for profit system. (If we knew the truth on these issues we would realize it cannot be fixed.)

      Single payer, which means no insurance companies, however, runs into the WTO GATS agreement. But, we need single payer, which means NO insurance companies (not some crippled last resort plan for the sick which is forced to charge huge premiums or be really horrible care by the fact that the insurance companies cherry pick all the healthy profitable customers.

      Single payer is quite different. Also, in part because of WTO rules, it must be free.

      Basically, we Americans are denied affordable health care, because of the past three Administrations’ – especially the current Administration’s truly horrible trade policy. Both parties seem to coordinate- to cover that up.

      If you want a very short one page explanation of several key trade agreement concepts which are causing these problems, (“investor-state”, expropriation, standstill clauses, etc.) read the section “A Cautionary Tale” from this article about the NAFTA “free trade” agreement – which was the prototype for many other FTAS- its basically Page 9 of this PDF. For a much better, but longer explanation, read this paper.

      Note that they are now, (five years after the 2009 paper above) trying to use the aforementioned clauses in the FTAS to lock in the for profit system forever, as happened with South Africa and quite recently, Slovakia.

      I think that must have been their plan from the beginning.

      Note that neither South Africa or Slovakia discovered this huge, hidden gotcha until after their people had voted for, and they had passed a public healthcare law and were in the midst of implementing it, when suddenly they were threatened with international suits before unaccountable arbitration bodies for huge damages for new bizarre free trade agreement torts.

  9. impermanence

    Although there is certainly plenty of blame to go around for the disaster that the U.S. health care system has become, the folks that have the ability to initiate serious change are the health care providers themselves, as they are the only people licensed to practice [imagine a country-wide strike by doctors!].

    Unfortunately, the leadership of the professions have completely sold-out to the corporations [in all kinds of ways], trading a slight income boost [that insures these miscreants can maintain their Mercedes payments], for a system that destroys the health and well-being of nearly the entire population.

  10. Banger

    Lambert you provide the best coverage on this issue that I know of. Having said that, the whole ACA thing makes me very sad and I don’t know what to say but to encourage people to explore alternative care. Even mainstream docs are beginning to accept the fact that both our physical and psychic disease stem form stress–the figure I’ve seen is 80% which is something to think about I should think.

  11. Paul Tioxon

    Lambert,
    I feel your pain.

    Here is something for the readership to look over, about the Health Care Coops that are an alternative to market place for profit plans. Not all states have had people take the initiative to form these, but where they are formed, there is chance at getting a better deal.

    http://nashco.org/

    1. kareninca

      Have you read this article that just came out re health care coops? They are off to a decidedly “mixed” start: http://online.wsj.com/articles/mixed-bag-for-health-co-ops-1402531423

      “Minuteman Health in Massachusetts had hoped to enroll 37,003 members in 2014, but reported only 1,435 sign-ups through April 15.”
      versus
      “Consumers’ Choice Health Plan of South Carolina—which predicted 19,204 sign-ups for 2014 but had 51,506 by May 1—had the lowest premiums in many parts of the state.”

      It looks like there will be some really big government loans to many of them, that won’t be paid off. The ones that are doing well in enrollments, are the ones that are were able to undercut the competition’s premium costs.

    2. diptherio

      I would point out that the Health Care CO-OPs are not co-ops in the normal sense. CO-OP stands for Consumer Operated and Oriented Plan Program. While I wish them the best, and John Morrison, the head of NASHCO, is a good guy (he used to be Ins. Comm. here in MT and was a good one), there have been a number of constraints placed on the CO-OPs that private insurers don’t have to deal with.

      Although the co-op plan originated in the Senate, resistance to the initial proposal quickly materialized on Capitol Hill, in part because of pressure from insurance industry lobbyists.

      So Congress saddled its new creations with onerous restrictions that, experts say, doomed many co-ops to failure. Federal grants for the co-ops were converted to loans with tight repayment schedules; they were barred from using federal money for crucial marketing; and they were severely limited from selling insurance to large employers, which represent the most lucrative market.

      http://www.washingtonpost.com/politics/health-co-ops-created-to-foster-competition-and-lower-insurance-costs-are-facing-danger/2013/10/22/e1c961fe-3809-11e3-ae46-e4248e75c8ea_story.html

      My CO-OP in MT here was unable to offer me a plan with affordable rates (although I fall in the O-Care donut hole–too much for Medicare, not enough for subsidies–so that’s not really their fault), in fact all of their plans looked pretty much identical to the BCBS options.

  12. bluntobj

    There’s a further wrinkle that we will not see an answer to until next year.

    The wrinkle that has never been discussed is the order in which your payments are applied to your tax liability; When you owe tax at the end of 2014, it will include any penalty tax you may owe for Obamacare. When you send a check in to pay, or even when you withhold over the course of the year, to which tax will your payment be applied first?

    There is nothing in the ACA or preliminary regulatory rulings from the Service in this matter. Don’t blast the tripe that you can choose not to pay the penalty; we do not know how the form will be structured, nor the payment order.

    The nice bit about this is that the Service will be able to apply your tax payment to your Obamacare penalty, then you will be short in your payment of your 1040 liability.

    Which can then be used to fine you, attach your assets, or imprison you.

    I would greatly desire an authoritative answer on this straight from the Service’s regulation or tax court rulings.

  13. Bill

    Strangely no one is talking about the mandatory fees- there are 3 of them, administrative in nature adding up to over $60/month, and if you don’t have dental- you are forced to buy ‘pediactric’ dental for a slight fee- BECAUSE THE LAW REQUIRES IT!!!
    I’m over 50 yrs old and currently I’m paying for pediatric dental, but receive zero coverage.
    Oh, and maybe dental might have been offered to me as an option, but after spending 3 hours on hold because the website was hopelessly FUBAR, I just did not have the energy pursue it.
    Multiply those fees by millions of subscribers, is that not a windfall profit? Sadly for we e the people the H.I.C. now has the same green light given to the Bankers, that is, help yourselves to rentier fees. The 25% annual premium increases are probably there just so the pres can show the American People he’s not a Socialist.

    This morning I saw an advert for this enterprise in my FB feed.
    http://luxuryresidentialsecurity.com/
    Perfect for secure gated hillside communities, protection from those pesky citizens. :-(

  14. Kmurp

    Most of the insurers in my area that are offering plans through the exchange are local non profits. Their plans are expensive as well.

  15. mellon

    People should be aware that the ACA, as well as “public option” literally cannot work, it cannot do what it is supposed to do, because of adverse selection. They knew this from the beginning because of repeated failures of similar plans in the states.

    See http://www.pnhp.org/states_flatline/State%20Health%20Reform%20Flatlines%20IJHS%20-%202008.pdf as well as the other research papers collected at http://www.pnhp.org/resources/pnhp-research-the-case-for-a-national-health-program generally.

    Also, please be aware that the real issue is something which both parties are bending over backwards to hide, TRADE POLICY. Example here, page 9 and especially, here.

    The entire rest of the situation is arguably a big lie, a diversion! The FTAS are the CORE of the problem.

    Investor-state and standstill clauses, etc. in particular.

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