ObamaCare Roundup: Counting, Court Cases, Corruption, Narrow Networks, and an Amazing Catch on the Filibuster

By Lambert Strether of Corrente.

ObamaCare needs no introduction, and so without further ado:

Counting ObamaCare Enrollees

I’m not going to play the numbers game, at least not for long. But here are the numbers anyhow! From the New England Journal of Medicine:

[N]umerous factors, including the economy, survey sampling error, and preexisting trends, can affect estimated rates of Americans without insurance. More generally, the systemic changes brought by the ACA pose a particular challenge for identifying the effect of the law, owing to the lack of a control group

As I kept saying, the numbers are soft. More:

We used three approaches to test for associations between the ACA open-enrollment period and coverage changes, using the largest national daily poll on health issues, the Gallup–Healthways Well-Being Index (WBI). ….

Combined with 2014 Census estimates of 198 million adults 18 to 64 years of age,19 this corresponds to 10.3 million adults gaining coverage, although depending on the model and confidence intervals, our sensitivity analyses imply a wide range from 7.3 to 17.2 million adults.

Wowsers, that’s quite a range! Anyhow, the all-important headline reads “Study Estimates 10 Million Americans Gained Health Coverage” so, whatever. Now, if you step back a minute, you’ll see the Alice in Wonderland quality of so much of the Obama discourse. Think about it: Would we be determining the number of Social Security recipients on the basis of a Gallup Poll with a ginormous margin of error? (Not ’til it’s privatized, anyhow.) Would we be making policy decisions on that basis? How about the number of troops in the Army? No? And yet this seems perfectly normal for ObamaCare.

For my part, I think playing the numbers game was just as silly as betting on the collapse of the ObamaCare website. I believe there should be equal access to health care for all, and so the fact that ObamaCare helps some people is just proof that it doesn’t help all, equally. Why is the random delivery of government services considered praiseworthy? So, to me, the entire “debate” presents the not especially edifying spectacle of the Republicans painting themselves into a corner by depicting RomneyCare as a socialist plot (I wish!), while the Democrats throw thousands of people under the bus while piously proclaiming their policy bona fides and good faith. And the health insurance companies laugh all the way to the bank.

Halbig v. Burwell and King v. Burwell

And I’m not going to talk about Halbig v. Burwell or King v. Burwell (which say that ObamaCare policies purchased through state exchanges either cannot, or can, be subsidized, respectively, depending on whether the actual text or putative Congressional intent determines the interpretation of the law). If the Roberts Court wants to scratch out “cat” and write in “dog,” because they feel Congress intended “dog,” they have the prerogative, bless their hearts, so there’s no point fussing. Which won’t prevent people from doing just that! And fortunately I’m not the judge who has to figure out the impact of Pelosi’s famous statement that “[W]e have to pass the [health care] bill so that you can find out what’s in it.” First, with Halbig and King winding their way up to the Court, Pelosi’s words have come true in ways that we never dreamed of. More importantly, if we take Pelosi at her word, is it even possible to determine Congressional intent? And although I like Sarah Kliff’s work, determining Congressional intent by reading columns in WaPo seems like a very odd suggestion indeed. For starters, why WaPo? So where do we look to determine intent?)

Flexian and Corporate Corruption

And I don’t want to talk about corruption. I don’t want to talk about the kind of corruption where neo-liberal Flexians infest public policy and private enterprise, shaping both to their ends. But Donna Smith does:

Remember Liz Fowler? She was the WellPoint executive who took a brief sabbatical from her direct paychecks from the private health insurance industry to write the Affordable Care Act while working for Senator Max Baucus. Once that project was wrapped up, Liz went to work briefly for the U.S. Department of Health and Human Services as she transitioned her way back to work as a lobbyist for health industry giant Johnson & Johnson. [Actually, Fowler visited the White House, too, to meet with at least one stock picker.]

I met with Fowler once in Washington, D.C. I was part of a delegation of people hoping to be heard on single-payer, improved and expanded Medicare for all for life health care reform, and she had the most sincere, concern-filled gaze I had ever seen in D.C.

But Fowler’s not the only one. Smith continues:

Now, in Colorado, we’re seeing Patty Fontneau, the CEO of the health insurance exchange, making her departure to return to private industry. Fontneau will take a position as president of health insurance giant CIGNA’s private exchange business. Prior to heading up the exchange, she worked for a law firm and in finance. No doubt her new role at CIGNA will provide her an income that supports the lifestyle to which she became accustomed while earning nearly $200,000 annually (plus bonuses) as the head of the Colorado exchange. It’s a safe bet she never had to apply for or worry about any tax credits or subsidies to cover her own health insurance premiums.

No doubt Fontneau’s gaze was sincere too. If you can fake sincerity, you’ve got it made. Smith concludes:

It is an affront to the basic common sense of most Americans and Coloradans to ask us to think that executives like Fowler and Fontneau have not been rewarded for their loyalty and success in protecting the big business interests that drive our health system.

It’s the genius of our Federal system that every state exchange provides a niche for Flexian infestation. And I want to talk about institutional corruption even less than personal, though Bob Laszewski’s come up with a doozy. We’ll go to the Obots at Kos for the spin — “Good Obamacare news: UnitedHealthcare jumps into market” — but Laszewski actually knows what he’s talking about:

United’s strategy of laying back a year letting the other guys pick-up the first year sick people and then making sure in 2015 to be able to keep and compete for the more healthy pre-Obamacare legacy business looks like a very savvy underwriting move to me.

The new health law does contain a risk adjustment system that is supposed to discourage any risk selection strategies by insurers. But if the experience with risk adjustment in Medicare Advantage is any indication, there is plenty of room for improvement.

I am sure UnitedHealth will now get plenty of plaudits from the administration and Obamacare supporters for expanding their public exchange presence arguing this announcement is proof of the new law’s sustainability. So, on top of being a savvy underwriting move it will also turn out to be a shrewd political move for UnitedHealthcare––a division of United is also the Obama administration’s lead federal health insurance exchange contractor. [And what a job they did!]

Think about it. They implement an old-style underwriting/risk selection strategy and the Obamacare supporters applaud them for it!

Savvy and shrewd.

Sounds like something out of Netflix’s House of Cards.

Indeed. Face it, ObamaCare isn’t really care at all. Like all insurance, it’s a financial product. And it’s part of Obama’s genius — he really is the more effective evil — that he’s managed to turn an entire political party into a sales tool for the FIRE sector. And guaranteed them a market, too!

Narrow Networks

However, I do want to talk about narrow networks, because NC readers know we warned about them, vociferously. Kaiser Health News:

Nancy Pippenger and Marcia Perez live 2,000 miles apart but have the same complaint: Doctors who treated them last year won’t take their insurance now, even though they haven’t changed insurers.

Both women unwittingly bought policies with limited networks of doctors and hospitals that provide little or no payment for care outside those networks. Such plans existed before the health law, but they’ve triggered a backlash as millions start to use the coverage they signed up for this year through the new federal and state marketplaces.

Note that there’s really no easy way to get an overview of ObamaCare problems even when they’re on the scale of (potentially) “millions.” The reporting system is fragmented across all the exchanges and two levels of government. Complaints will be routed to the individual insurance company, or possibly navigators, or state insurance regulators. And “No results found for PPACA +ombudsman” (Readers?) If we want to track complaints that people have with ObamaCare’s products and services — and if you’re a Democrat in an election year, why would you want to do that? — we’re orders of magnitude worse off than we are with taking a simple headcount of ObamaCare enrollees. ObamaCare, as a system, isn’t even architected to do the job. So who do we outsource job over to? Gallup again? J.D. Power? Obama For America?

The policies’ limitations have come as a surprise to some enrollees used to broader job-based coverage or to plans they held before the law took effect.

“It’s totally different,” said Pippenger, 57, whose new Anthem Blue Cross plan doesn’t pay for any care outside its network, although the job-based Anthem plan she had last year did cover some of those costs. “To try to find a doctor, I’m very limited. There aren’t a lot of names that pop up.”

Consumer groups argue many enrollees were misled. In California, consumers filed class-action lawsuits against some insurers, alleging they were given inaccurate information about their plans’ limitations and about which doctors and hospitals participate in them.

And, as we warned, the narrow networks put citizens at the financial risk that ObamaCare was supposedly designed to avoid. Patients can either go out of network by accident (or through being gamed by hospitals) or because their network doesn’t offer care they need or because of emergency:

Going out of a managed care plan’s network often means patients foot the entire bill, which can be financially devastating in cases of serious illness. In other types of insurance plans, a portion of the out-of-network bill might be covered, but consumers still face sharply higher costs than if they see a network provider.

(See here for additional material on narrow networks in Florida and here for Colorado.)

The Democrats and the Filibuster

Finally, I’m going to skip over cherry picking by health care “sharing ministries,”  an obvious way that insurance companies can game refunds to “consumers” under ObamaCare’s 80/20 rule, the reaction of New York “consumers” to rate increases, automatic renewal screwups, and how those pesky back-end 834s (here) are still FUBAR, at least in Connecticut. (For tech dudes and dudettes, this is unconscionable.) But I’m saving the best for last! Brett LoGiurato in Business Insider has an amazing catch that, alas, he does not see the implications of: 

How Harry Reid Might End Up Saving Obamacare

Democratic Senate Majority Leader Harry Reid might have saved Obamacare by going “nuclear.”

Last November, Reid pushed the button on the so-called “nuclear option,” dramatically changing Senate filibuster rules to get more of President Barack Obama’s judicial and executive nominees approved. Reid’s rule change allowed Obama’s nominees to be approved by a simple majority vote rather than with the support of 60% of senators, which prevented the Republican minority from blocking the president’s picks.

And it turns out, Reid’s maneuvering might become the White House’s most effective weapon as it faces the most serious legal challenge to the Affordable Care Act in more than two years.

“It’s the first big case where the effects of the nuclear option could be felt,” one Senate Democratic aide told Business Insider last week.

Here’s how Reid’s senatorial nuke could theoretically save Obamacare. Last week, a three-judge panel on the D.C. Circuit Court ruled that a 2012 IRS regulation that implements key subsidies under the law is invalid, in the case of Halbig v. Burwell. The decision has the potential to affect more than five million people who have been given tax credits when purchasing health insurance through the federal exchange.

But the Department of Justice is appealing the panel’s decision, requesting an “en banc” review by the full D.C. Circuit Court. The math for the Obama administration is better in this situation — the court splits 7-4 in favor of Democratically appointed judges, because of Reid’s rule change.

(I’m going to pause for a moment to give the mealy-mouthed yet somehow reptilian Reid a moment to savor the hagiography he must so rarely receive. [pause]. All done!) If Reid — and here we’re entering the Alice in Wonderland world once again — could invoke the nuclear option in 2013 to get a few judges on the bench to save the mountainous labor and mouse-like results of RomneyCare ObamaCare, then why couldn’t he have invoked the nuclear option in 2009 for single payer, when the Democrats had a mandate for “hope and change,” controlled both houses of Congress, were led by a charismatic President universally hailed as the greatest orator of the age, and could have saved thousands of lives and hundreds of billions of dollars? A question that answers itself, once you ask it. 

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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.

100 comments

  1. Banger

    Lambert, if the Republicans gain the Senate in November would you favor the repeal of Obamacare? Not sure if it can be done but if it could would you favor that?

    For myself, I can only say that I don’t know. I feel the ACA, for a number of reasons, is worse than what we had before despite the fact that many do benefit from some aspects of the law. One of the reasons I have always felt ambivalent about any HC reform is that I not only object to the insurance-centric aspect of the HC system but I also do not believe the current medical paradigm is healthy. One of the benefits of the pre-ACA HC system was that it encouraged alternative health methods that are, in some cases, far superior than the drug first/operate second/ask questions later attitude. There are benefits to the scientific approach to medicine but I don’t believe the current approach is all that scientific. A few years ago someone (sorry can’t remember who) made a study of medical studies and showed that most of them were either deeply flawed or came to very questionable conclusions. The current medical model rewards expensive procedures and does not like simple and inexpensive remedies.

    1. George Hier

      The GOP is as likely to repeal Obamacare as they are to finally pass legislation overturning Roe v. Wade: i.e. not a snowball’s chance in hell. Obamacare is far too good a fundraising target to ever want to get rid of it entirely. At most, they’ll nibble off pieces of it here and there, but they’d never dare a full repeal.

      1. mellon

        Obamacare is what it is because of the hidden and little known constraints imposed on it and the country by free trade agreements– which are “externalities” that are unnecessary, they were written, so goes the cover story, to be a tool to force other countries to privatize and deregulate, irreversibly.

        But, also to be a tool to force us into keeping the bad system we have now, forever, irregardless of what the people want.

        To use “trade” as a pretext to force the same un-affordable private for profit health care only constraint on us, on our own country, in an irreversible, legislator and election proof way, undemocratically.

        These FTAs have major blow back on us. Locking US in, is arguably, their main intent. because our market was then the most profitable, and probably still is, at least for now. Also, they abuse psychology of resentfulness and the fact that they havekept the people wholly in the dark. While other people are told that Americans are getting rich off of them. Really. Even though, we aren’t. In fact, the health insurance and drug industries combined employ less than 1% of the population.

        Can people see why they are being pushed so aggressively? It would not do for the homeland to get a better deal, though, not now or ever, no matter how much we need it. Even if 100,000 Americans die each year because they cannot afford health care. This is a crime- against humanity, I feel.

        The trade angle, is a pretext and a justification to elites. It is why they are being so shameless about their manipulation of their home land, even at tremendous cost, and getting away with it..

        They have succeeded in part because the subject matter is abstruse and difficult to write authoritatively about without the help of experts, who are very expensive. But, the information is out there, although hard to find.

        Get an idea of the limits imposed on Lambert’s state, (Maine) and its then Dirigo Health plan by one of the two the first FTA’s that imposed a standstill, the WTO General Agreement on Trade in Services- as of 2006 in this draft report linked here. (the other was NAFTA, its standstill and ISDS aspects you can read about on page 9 here That was way back in the mid 1990s- and then the media, diverted by the Clinton health care plan, completely missed the back story- that these agreements blocked new public health care, they said, irreversibly.

        Emboldened by their success in hiding something So important, it seems that was a green light to further feigned ignorance by Congress and the Senate, and the media. So, its been a 20 year long cover-up of the biggest giveaway in history!

        A giveaway for no compensation of our health care future, so a tiny well connected bunch of corporations can parasitically menace the rest of the world, coercively. A debate IS going on about this in the UK– because they are trying to use these new FTAs to privatize the NHS!)

        They will undoubtedly make it far worse,eventually, silently, giving corporations still more entitlements to stay in markets, a gift which by all accounts is totally unnecessary in developed nations, but the US seems to be the one that wants them the most, especially the unpopular ISDS, standstill and ratchet, showing that their real goal is to frustrate single payer here at home. Creating entitlements which further block single payer. (which is already blocked but semi-ambiguously, by their ‘standstill’ and ‘ratchet’ (Definition is from MAI) clauses, which apparently by ambiguous language in TiSA, its implied may look back, to GATS’s signing dates for countries, in 1995- Why?) Why have they kept trotting out the same wish lists of bad ideas, in agreements which have failed, first with MAI, then with FTAA, (they failed both times), and now again with TISA?

        They are blocking the only kind of health care which could work and be affordable, behind our backs . Is anybody even reading what I’m writing here, or trying to understand it?

        The fact that the original lock in appears to have stated in the 1990s, but the Democrats continued to hint single payer was an option, screams cover up to me. I believe both parties are cooperating in a cover up – and only pretending at gridlock, in a sort of good cop bad cop Overton Window shifting routine. Obamacare, which even I knew could not work, because it contains nothing new – and it can’t control costs, and it maintains the huge inefficiency, was designed to fail, when that is not necessary, single payer would fix all that. So,, its a manufactured crisis, which can then be exploited to justify the radical medicine of truly horrible, attenuated health care, narrow networks, gag clauses, capitation, (i.e. “pay for performance” or “pay for non-service”) This is in order to shaft the people out of a workable solution – This is being done for their corporate donors, so the US can suck its people dry while preserving the too large slice of a shrinking pie consumed by the parasitic health insurance sector, which adds no value.

        Their biggest, most ambitious goal is to use the FTAs- like TiSA, TTIP and TPP to kill public health care in other countries, kill the hated drug price controls elsewhere, (which also necessitates that we NEVER have them!). Export their parasitic model of bad – but very profitable, profoundly unequal, unfair health care elsewhere. Hijacking democracy and our planets future. Dismantling the global safety net.

        1. Oregoncharles

          The FTA’s are essentially legislation – that’s why they require BOTH houses of Congress – and can be repealed any time Congress overcomes its fundamental corruption.
          Which may mean you’re right: it would take a revolution. At the very least, an electoral revolution.
          Note: the Green Party in the US has opposed them all along.

          1. mellon

            They can’t be simply repealed once the ISDS entitlement kicks in. There is a discussion of that somewhere in the Achmea v. Slovak Republic case decision. I think its a general principle. It takes some really long time, like, ten years after they say they are pulling out. They are designed to make it impossible to leave. For investors.

            1. hunkerdown

              Well, there is the extremely unlikely event of a sufficient bloc of states repudiating the treaty simultaneously; declaring relevant tribunals and assemblies terrorist orgs; and ideally some unpleasant weeks under martial law rooting out the capitalists, but like I said, extremely unlikely.

              Self-defense is almost always a legitimate justification for the use of reasonable force, and you bet these trade agreements are a form of terrorism by non-state actors.

            2. Nathanael

              Free trade agreements can simply be repudiated. Like all treaties. Bush Jr. repudiated an arms control treaty. Any treaty can be repudiated outright with zero compensation.

              Worth remembering: in the wake of the Great War, hundreds of international treaties were repudiated and became dead letters.

          2. hunkerdown

            Depends on how much other members want that member to stay in. In USA’s case, I imagine many other parties to these agreements, certainly among the non-aligned, would greet the news with something between rapt joy and indifferent mumbling about doors and derrieres (if they have other buyers for their wares, anyway).

            But certainly not all. Paul Singer and friends already tried to impound a sovereign nation’s military boat — that there are not people breaking rocks forever in Argentine labor camps for even thinking of messing with a military vessel is disappointing. Were a nation to pull out of a “expected future profits” type of agremeent and deny the investor class all that upside, look at what hell Igor Kolomoiskii raised and is continuing to raise in Ukraine, then imagine the sort of synergies lots more butthurt absentee owners and lots more private mercs might realize. The deep state’s response to that situation would be questionable, at best. “Duck and cover!”[1]?

            [1] “Can you state that in the form of a desperate cry to God to save you from an unholy death please!

            1. different clue

              The Ruling Overclasses of all these countries would want to keep the US stuck in these FTAs because the Ruling Overclasses of many other countries share the same class exploitation interest with our own Overclass that our own Overclass shares with the other Overclasses.
              For example, NAFTA enriched/enriches the Overclass of Mexico AND America and exploits the nonOverclass of Mexico AND America. So don’t expect the foreign governments to let America leave these FTAs quietly.
              If we elevated a Revolutionary Protectionist government to power here and abrogated all the FTAs, going all the way back to GATT Round One if necessary,
              the rest of the world would treat us exactly the same way as the rest of the world
              treated the infant newly-starting-out USSR in the years 1918-21.

    2. fresno dan

      “Lambert, if the Republicans gain the Senate in November would you favor the repeal of Obamacare? Not sure if it can be done but if it could would you favor that? ”

      64,000$ question (or nowadays, 640 billion dollar question)
      It seems to me our reforms are always the same – tax breaks, subsidies, and barrels of money that cost 100$ to provide 1 $ of benefits to the poor or less well to do. Than the narrative can be constructed about how the poor are still poor but we are spending a fortune on the poor (when we’re spending in fact a fortune on the suppliers).
      How much should giving birth to a baby cost?????
      http://www.cnn.com/2012/12/02/opinion/greene-birth-bill/
      OR
      http://www.workingmomsagainstguilt.com/2008/04/the-cost-of-having-a-baby-in-1950/
      OR
      http://www.oftwominds.com/blogjuly09/healthcare07-09.html

      So, medicine is better – babies live today that would have died in 1950 (but not THAT many – the vast majority of babies are fine). So why is it that TVs that are much, much, much better than in 1950 and are so much cheaper in real terms than health care???? For what we pay for health care, we should be damn near immortal.
      I would submit just like there is a cabal of CEO’s and such who can manipulate their compensation (despite overwhelming evidence that they add little value, and are often responsible for catastrophic failure – and Yet, still get bonuses abetted by the US government….AIG), and that doctors are in a like cabal. Regulation does not so much impede they’re depredations as provide a cover. Medicare’s outrageous inability to negotiate truly is an astounding ravishing of the taxpayer. Nary a peep from Republicans who have a very inconsistent philosophy about saving the government money when cronies are at the trough.

      Pretty much 40 years of income stagnation and losing ground for the lower quintiles. At some point, what really amounts to another net transfer of resources from the poorer to the richer cannot be sustained. Sooner or later, government reforms can’t just be passed by buying off the wealthy – there just won’t be the resources.

      1. mellon

        Several people I know have moved to Europe, just because they had jobs or spouses there and they felt it was a better place to raise their kids.

        You ask “if the Republicans gain the Senate in November would you favor the repeal of Obamacare? Not sure if it can be done but if it could would you favor that?” Repealing Obamacare wouldn’t improve anything, because its not the problem, things like WTO/GATS are. They block the kinds of changes which would make health care affordable.

        The reason Obamacare is such a bad deal is the FTAs basically block any kind of good health care setup. And that’s (in part) what they are designed to do.

        What needs to happen is all the free trade agreements would need to be sacked, and obviously, new ones could not be passed. Core tenets of the FTAs would need to be revisited and if the ISDS provisions had kicked in the owners of the invisibly, silently created rights in those market sectors (such as insurance companies, energy companies) would need to be compensated, at ENORMOUS cost, (see GATS Article 21) which in the case of health care or energy the mandated fine would be so large as to bankrupt the government –

        The newer ones are particularly bad, because what’s called the US style FTAs use what’s called a negative list – unless a market sector is completely excluded, beforehand, they prohibit any kind of new public health care (or other services) out of hand. They have an implicit framing that public services are bad and that the end state is privatized everything. GATS created a one way street with no going back possible, to privatization. This started with GATS and NAFTA back in the 1990s.

    3. different clue

      The Establishment Rs will never permit Ocare to be repealed. They support Ocare for the same reason that
      Roberts upheld Ocare, to profitise the insurance companies through the forced mandate revenue stream conduit. The Establishment Rs merely preTEND to oppose Ocare when the microphone is on and when the cameras are running.
      If the Tea publicans try repealing Ocare, the Establishment Rs will join the Democrats in preventing that repeal.

      Now, what the Establishment Rs WILL do is to try “improving” Ocare to make it more purely Heritage. Whatever they change, they will definitely preserve the forced mandate. And they will get enough Democratic support to make it happen.
      And that was one of the points of the Ocare excercise. Ocare is the legal equivalent of a “stub” on wikipedia. The Ocare stub is sitting there waiting for refinement into its Heritage end form.

      1. Code Name D

        Not so fast. You are assuming Republicans can’t come to the insurance industry with an even sweater deal than what Obamacare provides. And they have something already waiting – Health Maintenance Accounts.

        As bad as Obamacare is, it’s still based mostly on a pay-as-you-go approach. People buy insurance to pay for healthcare needs for that year. Healthier individuals who will end up paying more into the system because they need little healthcare will end up subsidizing the older and sicker generations who simply can not afford their care. While Obamacare dose so through a basterdized maze of privet toll-gates and corporate skim operations, cost sharing is still a sound idea.

        HMAs however wants to use a strategy similar to retirement savings. Younger persons pay into a privet fund which is invested into stocks, bonds, and other investment portfolios. These funds will then be drawn down upon during the older years when healthcare needs become more significant.

        If you think healthcare is bad now – wait until you let Bank of America get their greedy hooks into it.

        1. mellon

          Its been brought up many times that the only way that Obamacare style “consumer driven” insurance works for people is if they are BOTH

          1.) rich and

          2.) healthy

          Everyone else should not buy these cheap low actuarial value plans or when they get sick the WILL get dumped by the sudden bills. Its virtually guaranteed.

          I think that they long ago crossed the threshold where a majority of people couldn’t afford the current for profit system. (In the early 90s) That was masked by the fact that most people had employer provided insurance but that is now changing. Also, costs have gone up and wages are flat. The last time I read a (Fed- something about sustainability of health spending growth and “crowd out”) paper analyzing this was in 2008 or 2009 and at that point only the wealthiest 14% could afford the for profit system and buy adequate non group health coverage. And that was using a very generous definition of what they could handle in terms of risk. And an assumption that they had some savings too. More than I think most people have today. The remaining 86% could not. Nothing has fundamentally changed except people have gotten poorer. So nothing they do short of switching to single payer is going to do anything more than tighten the ratchet/noose by more struggling (thats how the free trade agreements are designed to work, each click of their ratchet effect goes towards more privatization and a better deal for the corporations, IT HAS TO. **After all, they are guaranteed in the FTA’s “ISDS” clauses that IF governments do anything that effects them adversely, even if it is merely doing their jobs, the taxpayers of that naughty government suddenly become liable to pay them compensation!**

          (That is a recipe for serious corruption) IMO, *given that we are laboring under that condition which is allegedly irreversible and irrevocable, the best thing for us to demand they do is STAND DOWN, stop doing anything, what we should demand they do is stop doing anything at all because everything they do has to be a “bad” or a “nothing” it cannot be good.* What a mess.

          1. Aimai

            This is, of course, completely false. The poorest people covered under the ACA are covered under Medicaid. Second of all, the people covered under the ACA who were previously uninsurable are unhealthy almost by definition because they were uninsurable because private insurance companies deemed them uninsurable because of pre-existing conditions. Now, under the ACA, all Insurance companies must accept these people if they are paying the premiums and those who make little enough get subsidies. They get subsidies for Silver Plans in their local market. So the ACA is not at all designed to benefit just the rich or the healthy. You are talking complete nonsense.

            1. Lambert Strether Post author

              What you’re showing is that ObamaCare is fundamentally unjust because it’s a two-tier system of acccess stratified by wealth. Thanks for proving my point. I take it you’re OK with that?

    4. NotTimothyGeithner

      The Heritage Foundation Plan was meant as a poll tested poison pill for Team Blue as an alternative to Hillary-Care. The Teabaggers are a wildcard*, but the traditional Romney class wanted Team Blue to pass ACA to get the policy fleecing the American people but without being blamed themselves. The President’s party would be blamed by voters open to changing their vote.

      *I mean the rank and file voters recruited after the Southern Strategy and who represent the bulk of new GOP recruits since 2000. The Tea Party was a brand effort to prepare them for the Mormon from Taxachussetts who came from the GOP elite wing they despise. They loved W because he was an obvious drunk and black sheep.

      1. mellon

        That 1992 stuff – just like Obamacare, was all a *finely concocted bipartisan good cop bad cop theatrical performance* with the goal of covering up the shafting of the whole country and hiding the ongoing [WTO-GATS negotiations](http://www.pnhp.org/sites/default/files/Nick%20Skala%20GAT%20and%20Health%20Reform.pdf) which were going to [steal our right to have public health care](http://www.maine.gov/legis/opla/ctpchlthcaresub.pdf) and of course, single payer.. from then on – NAFTA had the same provisions in it too- [see Page 9 here](http://www.law.harvard.edu/programs/lwp/nafta.pdf) – SOUND FAMILIAR?

    5. Lambert Strether Post author

      No, I don’t. I’m not a worse is better kind of guy. It’s undeniable that ObamaCare helps some people, and it would be cruel to take that away from them. My beef is that ObamaCare does not and cannot help all, equally.

      1. Crazy Horse

        Just speaking of worse or better—– the second most expensive health care system in the world on a per capita basis in found in the Netherlands. The savings from converting our medical extortion system to a Dutch model of health care were recently estimated at one Trillion! dollars per year.

        Just what would an extra trillion dollars of discretionary spending per year buy?

        1- Elimination of all burning of coal and its complete replacement by a smart grid powered by liquid sodium fluoride reactors with zero possibility of melt down, 95% reduction in nuclear wastes, and that in the form of 300 year maximum radiation danger rather than 10,000 years.
        2- Or increase in the total transportation fleet economy to 75mpg by a combination of electric and European style high efficiency engines.
        3- Or lower the age of Social Security retirement to 60 and increase the amount to a living wage.
        4- Or super-insulate every home in the country and achieve a 40% reduction in energy usage.
        5- Or increase the renewable energy component of our system to 30-40%
        5- Or eliminate our Monsanto frankenfood oil based food production scheme and localize and naturalize food production.
        6- Or— ??

        Sorry Lambert, but the argument that Obamacare is better than nothing because it helps some people ignores the cost of lost opportunities. And if I do say so, it has echos of the argument that after all Obomber was better than the criminal Romney who built his fortune upon capital secured from Salvadorian death squad financiers, the vampire witch Hellary cackling as she watches Gaddafi gutted and put to death, or that senile lecher McCain rubbing his hands in anticipation as he chooses Caribou Barbie as his running mate.

      2. Crazy Horse

        Not to mention the other half trillion or more that if immediately eliminated from the Dept. of War budget would increase— not decrease our national security.

      3. mellon

        “Insuring” they have no ability to buy out of the system with cash and get honest health care any more. Our government is helping protect their jobs by freezing toxic chemical laws in TTIP even though we have a 25 year backlog of toxic chemicals that need action, I see.

      4. Oregoncharles

        It’s too bad the Supremes didn’t strike down the Mandate (which I think is clearly beyond Congress’s designated powers – actually, the Court did, too; that’s why they had to call it a tax).
        In that case, we would have had it both ways: the benefits would stand, but the most offensive portion, and the chief benefits to the insurance co’s, would be gone. Supposedly, it wouldn’t be fiscally sustainable, so it would gradually collapse. But the feds would still be on the hook for the benefits, so they’d have to actually improve it – hopefully into single payer.
        Any other way of knocking down the mandate would work, too.

        1. different clue

          But the mandate was the most important point of the law. The Mandate was what the Roberts court bent itself into pretzel-logic shapes to preserve and uphold. No way was Roberts going to permit his court to go rogue and disallow the mandate.

      5. different clue

        If the harm Obamacare causes some people adds up to more Net Harm Units than the good that Obama does for some people when added up to Net Good Units, then repealing Obamacare would do more actual good than keeping it, if the Net Harm Units cancelled outweigh the Net Good Units lost.

  2. trish

    I eagerly await the Reid spawn joining our numerous other dynastic spawn in looking over their vast and growing neoliberal empire and claiming what is rightfully theirs. Many faux-public servant-to-lucrative-corporate-position riches await them!

    as always, great coverage, comment on obamacare.

  3. PaulArt

    I recently quit my company to pursue a Ph.D full time. I signed up for Obamacare for my family. It took 15 minutes on the ACA website. I pay $194/month for both my wife and myself and my children are to be covered under Medicaid. If I took COBRA it would cost me almost $1300/month.

    As much as I appreciate the information Lambert has compiled in the pages of NC against the ACA for the last two years I think at some time we need to stop trying to cast out the baby with the bathwater. I am frankly getting tired of this. How should I put this? I could be locked in a room and forced to hear Tommy Emmanuel play his beautiful finger style version of ‘Amazing Grace’ but if that is the only tune he is going to play for 5 hours then I think I may be in danger of committing homicide.

    Yes, it is ‘half a league, half a league onwards’ for sure but what would you suggest till then? That all of us jump out of the only boat we have bereft of life savers? In my case do you want me to pay $1200 per month that I do not have? It is pretty ridiculous.

    Take a breather Lambert, I am left of Marx but your preoccupation with the negatives of ACA and the minutiae picking is beginning to sound mono maniacal and a little loony.

    1. diptherio

      Oh what, like there’s ACA stories getting posted every day? Come on man…you don’t like it, it annoys you, you’ve heard it all before…stop reading.

      And don’t you think it’s a little much to ask that Lambert to not only keep providing the real scoop on the ACA, but also figure out what we’re supposed to do about it?

      You’re happy with your coverage; I got a mandate to buy an insurance product I will never be able to afford to use. Now you get it? I’m happy for you that you like your insurance, but that is entirely beside the point.

      People man…”everything’s fine for me, so why is everyone complaining?” aaarrggghhh!

    2. so

      Glad it worked out for you. For me, not so much. 400 a month for an 8000 deductable.
      If I get sick it”s back to bankruptsy court again. As an artist and a furnituremaker I lost my shop and tools in
      2007. Thanks to this I’ve had a front row seat everyday to watch the scum (sorry god) sell us out.
      Thank you Lambert for your hard work. At least I can go somewhere for info. where I’m not getting screwed.

      1. Banger

        True for many people. The point here is that we are forced to buy what we don’t want. We need a network of simple clinics offering affordable care without the endless drug and operation routine–using holistic care which is now going to be less available as industrial medicine marches triumphantly onward.

        1. Doris

          In Massachusetts I’m paying $478.66 a month for an individual crappy plan, $45 more than under the previous corporatist plan.

    3. mellon

      PaulArt, you have it backwards, we are the ones being locked in a room, and we’re being forced to listen to the private health care tune, over and over again, coercively by the covert forcing of a known-to-be-broken private for profit model being forced on us

      Its being shoved down our country’s throat by the less than 1% of Americans who benefit, the owners of the insurance and drug companies, at a huge national cost – probably representing an extra quarter million dollars or more in costs to each American. Its being done undemocratically by means of secretive back room “free trade agreements” like the WTO Services Agreement from the WTO.

      This is also shown quite clearly – if you read it carefully, by this document, from Lambert’s own state, from 2006.

    4. Eureka Springs

      Here’s an dishonorable PHD in arrogant cruelty for you, America… right here in PaulArt. Why he just told millions of us, not just lambert, to F off and suffer endlessly and or die.

      Thank doG, we can’t all be Paul.

    5. JohnnyGL

      PaulArt,

      I’m sincerely glad to hear that the plan seems to be helping you, but I’d like to you suspend judgement until you’ve actually A) found a doctor who accepts the plan and B) seen what kind of out of pocket costs you’re going to be stuck paying. C) Also, is the insurance plan going to actually pay as they’ve promised to pay? Yves has documented her bureaucratic hassles fighting with Cigna. She’s far from alone.

      I hope you don’t require enough medical care to really test whether the insurance provider is up to the task. But, if you do, that’s when you’ll really find out if Obamacare is “working” for you or not.

      You may think it’s time to declare victory now that you’re “covered”, but really, the battle is about to start. I hope your confidence is not misplaced.

    6. Deloss

      Amen to you, PaulArt. The toast is, “Confusion to our enemies,” not “Aid and comfort” to same.

      It is annoying to hear Harry Reid called “mealy-mouthed yet somehow reptilian.” He did exercise the nuclear option when negotiation and offered compromise got us nothing. As a result, he has gotten us some reasonable judges. He aptly described the Tea Party as anarchists. Do you remember who was running against him? And I must say the same thing about this characterization of him as I did when somebody on here described Paul Krugman as a “whore”: quel goût exquis!

      1. Lambert Strether Post author

        “mealy-mouthed yet somehow reptilian.” I’m glad that was annoying; that means I’ve got my tone and register under control. Assuming that Reid was acting in good faith, and felt, in 2009, that the same party that impeached Clinton over a **** *** and stole election 2000 was amenable to compromise, he was at best a fool (along with the rest of the Democrats, including Obama, who may, again assuming good faith, have bought into it as well). As for calling the Tea Party anarchists, that’s just ignorance and name-calling. I know people who fall into both categories, and they’re not the same at all.

        NOTE In general, I deprecate the trope that compares legacy party political operatives like Krugman to whores; it’s insulting to whores.

          1. hunkerdown

            I’ve seen the term “predictive programming” more than usual recently. That must be what calling FDR liberal was all about. Now we have proud liberals who go wherever the label takes them.

    7. sgt_doom

      OK, perhaps you are completely justified in what you say, you are one of the fortunate ones, but how does it affect the majority of Americans? The majority of workers? And does it affect the type and qualiy of care actually received?

      For a more comprehensive summation of both Obamacare, and health under capitalism, there exists a wonderful book of essays by some really top notch thinkers: Morbid Symptoms, put out by the Socialist Register.

      Also, a complementary talk given at the recent Washington state chapter of Physicans for a National Health Program, by Seattle’s councilmember Kshama Sawant:

      https://www.youtube.com/watch?v=Jc1g9G0g5xw

    8. Benedict@Large

      Good for you on your success with ObamaCare. There certainly are some good stories out there, in particular the Medicaid expansion and (sometimes) the premium support.

      Unfortunately, for all of the good stories, the ACA has some severe structural problems that net it out as a worse system than before (Disclosure: I’m an ex-health insurance exec.) The most immediate of these problems is that high deductible plans (which describe pretty much everything available on the exchanges) for low income people are pretty much useless. Let’s face it; no one qualifying for a 100% subsidy is going to be able to afford $5,000 up front before care can begin. The second of these problems, and this will be increasing encountered as ACA gets into it’s third year and beyond, is that people will be shifted out of employer plans and onto the exchanges (individual plans), which are substantially worse. (They pay less, and have much worse service.) Worse, these shifts will primarily occur in the lower half of the income spectrum, people who can least afford the lesser coverage. There are various estimates of how many might eventually be affected, but it could go as high as 80 million people, with the rate low at the start, but increasing rapidly once employers begin to see others doing it.

      The end effect of these two structural problems is a definite rationing of healthcare by income level, something admittedly present in the pre-ACA system, but at a MUCH lower level. ACA will show itself as very cynical attempt to cover over larger problems, in that it front-loaded the easily-identifiable goodies, while rear-loading most of its very severe shortcomings.

      1. Lambert Strether Post author

        I’d like to hear more from you on this… Given that you’re a former insurance executive. Where do I go, for example, to flesh those ideas out for a post? I’ve never heard them put quite so concisely. Feel free to contact me at my blog.

      2. mellon

        That is exactly what I have been trying to say. The insurance companies are experts at taking people’s hard earned money for years and dumping people when they get sick.

        Benedict, I need to know this. What do health insurance industry execs know about the FTAs like GATS?

        Also, suppose there were easy, cheap natural/food based ways to cut the nations health care bill dramatically, without doctors, would they want them, or oppose them?

    9. Oregoncharles

      You better check what doctors are in your network.
      The key point, which you’re actually confirming, is that some people benefit, as apparently you do, and some get screwed. That’s both unjust and inefficient.
      Anyway, look back at the beginning: 10 million covered out of over 30 million uninsured. Unless you’re one of those 10million, one whose plan isn’t too crapified (5 million, then?), the whole thing was a waste of time and money. 10 out of 300 is just SUCH great odds.

    10. Lambert Strether Post author

      Thanks for your concern. I always get a comment like yours, that boils down (as another commenter says) to “I’ve got mine! Now, you get yours.” This putative risposte is remarkably devoid of solidarity; indeed of basic humanity.

      You further impute to me the rhetorical question that “[Should] all of us jump out of the only boat we have bereft of life savers?” Of course, there’s nothing in the post that suggests this, and my position has consistently been that the issue with ObamaCare is not that it will not help some — these “some” including, as you point out eloquently and at length, yourself — but that it cannot and will not help all, equally. Perhaps you suffer from a case of the guilts, having climbed into the lifeboat while you can hear the screams of others drowning, and hence wish to cover your ears?

      * * *

      For the rest of your comment, it amounts to “Move along, move along, there’s no story here.” Others disagree. I’d suggest you simply use your time better in future, and not invest in subject matter you consider useless or upsetting.

    11. Code Name D

      So we aren’t even going to pretend to be concerned about the ongoing state of healthcare any more.

      Once Democrats step into the sun, the are usually singing the praises of Obamacare, how this will solve every thing and how Republicans are trying to steel grany’s healthcare. The triumphalism is frankly disgusting.

      And yet it doesn’t take a whole lot of reality to have them change their tune. The argument then becomes “the best we can do”, “no magic wands”, “better than nothing”, or “Republicans won’t compromise.” It seems that any shred of benefit, no mater how slight, or benefits so few, can be used to overrule the status qou.

      We are only concerned with defending the legacy and basking in our own delusions of adequacy. Any notions of real healthcare reform has died from the lack of oxygen in the room. Because all of the oxygen has been taken up by this rotting thing we call Obamacare.

    12. kareninca

      Ah, another “Medicaid Winner.” This happens without fail when NC posts an Obamacare article: someone like PaulArt pops up and tells of of how great Obamacare is because he is now on Medicaid and is getting a fab deal for himself. It is almost as if someone were paying for these endorsements.

      Guess what, PaulArt – Medicaid is not Obamacare. It is nothing like Obamacare. Your Medicaid experience is irrelevant to the many screwed purchasers of Obamacare policies, who are paying high premiums and have huge copays.

      If this were ZeroHedge, the consensus would be that a real man does not brag about not being able to provide health care for his family, and about getting the public to support them. That in the old days that would be a source of shame. Here, the focus is more on how the system has become so expensive due to corruption and misallocation, that even a responsible person could end up on Medicaid. So the question is – how will your family fare on Medicaid?

      Like I wrote, there is an “I’m a Medicaid Winner” post here each time there is an Obamacare article. But they are not then followed up by credible posts describing good care obtained by these “winners.” In fact, there have instead been anecdotes from people who reluctantly went on Medicaid, and now cannot get the doctors and care they got before. One was from a guy in his 50s with a serious, complex ailment, who both lost his doctors and who is staring at the clawback provisions – something you don’t seem aware of. Maybe you never plan to accumulate assets.

      What state are you in, PaulArt? Once I know, I can google around and find out how people describe the actual Medicaid care they get, and what version of the “clawbacks” is presently in force.

      1. Aimai

        That is false, too. Medicaid was a planned part of the expansion and is, of course, the beloved single payer. Just for the bottom portion of the economy. Its not separate from Obamacare–its integral to Obamacare.

    13. Lune

      PaulArt-

      I’m glad you were able to get cheap coverage (heck, I’d even defend your children getting medicaid; why shouldn’t society help you while you invest in your education which ostensibly will allow you to be more productive in your later years?)

      However, I would suggest you need to look at the actual details before deciding your new plan is better (it may be; I’m not automatically assuming it’s worse). To keep things simple, I’d ask 3 questions:
      1) What is your deductible and out-of-pocket maximum?
      2) How big is your physician / hospital network?
      3) What is the coverage for out-of-network care?

      Regardless of politics, I’d really suggest you find out the answer to those questions now before you (God forbid) get sick and actually have to *use* your insurance. If you have and you’ve determined that overall the ACA plan is better for you, then more power to you (although given that half of your coverage is from Medicaid expansion, something even most anti-ACA liberals were in support of, your case doesn’t necessarily explain why the ACA needed to be implemented beyond the medicaid expansion parts).

  4. DakotabornKansan

    Great to hear that Obamacare is working for you while you pursue your Ph.D full time.

    But pardon me if I feel less than charitable toward your triumphant crowing about your Obamacare success.

    Your attitude comes across as a reprise of the old British expression, “I’ve got mine, Jack.”

  5. Chromex

    The other problem with the Phd candidate is that his/her children being on medicaid may have consequences for them later depending on what state they live in. Although medicaid has “expanded” to “cover” more people the quality of care for those on it is not good, as numerous articles and studies have shown.
    My situation is different from the Phd candidate and i am disadvantaged to the same degree that he was advantaged. he does not seem to think about other people or their situations. So apparently, your writing about the random nature of the ACA as to who it “helps’ has fallen on deaf ears.
    However, Lambert, as much as I hate Pelosi (and I think she IS not bright and likely did NOT know what was in the ACA), what you quote is a clause, not a sentence. If you read the whole sentence it is clear that she was pushing for passage of the law, which at the time had not passed and was generating much controversy, with the hope that all the shrill rhetoric about “death panels’ etc would die down and she and others could explain to the public ( the “you” in the quote) what they thought were the benefits of the act without being drowned out or misconstrued. She was not saying that she and other legislators did not know what was in the law, ( although it is likely that they did not, or did not have it adequately explained) she was saying that the public would not understand it until the heated rhetoric would die down. . She has made many statements worthy of ridicule, particularly in the area of “defense’ and “national security” and certainly what she thought would happen after passage has not taken place but the meaning of what she said is pretty clear and it is not what the cons/Drudge have distorted it to mean. And of course no court would pay any attention to it as a means of discerning legislative intent.

    As for your suggestion that the DC circuit 3 judge panel was correct, as an attorney, I also disagree. Again, this does not mean that the SC will not uphold them ( except if Roberts is going to save the act by calling it a tax it is likely that he will side with the law on this one). Bedrock principles of statutory constructions require not isolating one section of an act in order to interpret its meaning. When the act and the intent of the act is construed as a whole, Imo 9 out of 10 courts would side with the Obama administration. It just is absurd to postulate that Congress intended to punish individuals that lived in states that did not pass medicaid expansion in order to provide an “incentive” for such states. I wish this were not so, as i do not care for the act, and implementation of this decision would effectively gut the individual mandate ,which would be fine with me.
    i would continue to harp on narrow networks, deductibles, copays and ‘coninsurance’, drug forumalrys and the whole evil brew, which may yet come back to bite Mr. Phd candidate.

    1. Lambert Strether Post author

      I think you are probably right, in principle, on “bedrock principles of statutory construction.” However, it may be that the bedrock has been, as it were, fracked.

      What I would like to know is what the boundary conditions are; how wide the gap between plain language and evident intent has to be before it’s not OK for the Court to rule. I just don’t see how you can assume, always, that Congress even knew what it was passing; see the Pelosi quote. So given that context, how is the question of “intent” even meaningful? (For all all 2400 or 906 pages or whatever, much of it written, no doubt, by lobbyists and staffers.) And if the Supreme Court gets to determine intent on this massive scale — and this is the Court produced by Bush v. Gore, speaking of intent — where does that stop? Isn’t the “right” answer for the Court to send the law back to Congress and have them fix the language? Yes, the political context makes that a clusterf*ck, and it’s a result that one party would surely rejoice in, but are the presumed political consequences on Capitol Hill really a factor we want the Court to include in its decision-making?

      Frankly, I’m in “enough is enough” mode; it’s not the Court’s job to pull Baucus and Pelosi’s drafting chestnuts out of the political fire.

      1. Chromex

        Well if you read enough cases you see that courts know that legislatures generally do not know what they are passing so in a literal sense, the whole “intent” business is fiction. But if it is fiction for a court to say that the legislature “intended” X by what it wrote, it is just as much a fiction to say they intended the literal meaning of what it wrote. So its hard to attribute anything sacred to intent.
        I was a legislative drafter for years. The reason they hired drafters is because heaven help us if they drafted laws. Most of the ones I worked with could not even formulate basic ideas or even know what they wanted. SO its a backstop and not a good one sometimes but its better than nothing. Strict construction of individual sections of the law without considering the act as a whole would gore everyone’s oxen. Maybe you like the result in this case, in the next one, not so much. This is true for judicial construction as well, of course, but overall the effect is ameliorative, IMO. Legislatures are not something in which a religious-like faith should be invested, separation of powers notwithstanding. The entire body of miserable federal and state laws is completely riddled with these sorts of errors.Most lead to absurd or harsh results that no one can be said to have intended. When you badger and pressure drafters 24-7 for no reason to meet an arbitrary deadline to fit your political ambitions, what could possibly go wrong? (BTW while it is obvious that Obama/Bauhaus did this , so does everyone else).
        The remedy you suggest is never easy, no matter the political climate.
        You ever tried to amend a law that needs fixing? EVERY amendment becomes a political football, no matter how innocent/needed the amendment is. This is because legislator A knows that Legislator B WANTS something and Legislator A wants to use this opportunity to get something he or she wants. . That’s why every legislative session is a cluster . If I had a nickel for every needed corrective bill I saw languish because the sponsor and/or agency did not have enough bargaining chips to satisfy the tinhorn legislative leaderships horse trade demands I could probably afford decent health care.
        My point is that most cases say, in giving effect to legislative intent we have to consider the whole thing that was passed, not one section. The reason that the federal exchange can and does enter the picture is there is no explicit prohibition and the act itself was clearly not meant to discriminate on subsidy availability. Sometimes what IS passed is so nonsensical that the courts give up. This is ok too, as you point out, some garbage cannot be salvaged.
        Moreover, there are a lot of people- the majority- that will be harmed if they can’t get already promised subsidies, speaking of hearing the screams from the lifeboat.
        Whatever you may think of the Supreme Court, and after Hobby Lobby , mu opinion of it can’t get much lower, given our imperfect humanity and likelihood of unintended , harmful mistakes, statutory construction is, on balance, a good thing.
        That does not mean that the ACA is good. It is not. It is truly awful. I am a single payer supporter all the way and much appreciate the yeoman’s work Corrente has done. .

    1. Oregoncharles

      They LOVE the filibuster, because it allows them to use the Republican bogeyman as a figleaf on their real agenda – which is the plutocrats’ agenda. (Yeah, I know mixed metaphor. I sorta like it, though.)

  6. timbers

    I too am glad PaulArt benefited from ObamaCare but I really appreciate Lambert’s information. When you spend $1.3 trillion dollars on ACA over 10 years or whatever, someone is bound to benefit. But so many more could have gotten more and better benefits if the law had intended to do so.

    One unfortunate aspect of issues Lambert identifies is that perhaps none of them are salient or widespread enough to reach a level of popular wave. But maybe that’s due to our media and pro-corporate Democratic Party. Seems all they want to talk about now is how turn Ukraine into Gaza because big bad evil Putin.

    1. Paul Tioxon

      For Lambert, This is an intervention:

      “I saw the best minds of my generation destroyed by madness, starving hysterical
      naked, dragging themselves through the negro streets at dawn looking for an
      angry fix, angelheaded hipsters burning for the ancient heavenly connection to
      the starry dynamo in the machinery of night,

      who poverty and tatters and hollow-eyed and high sat up smoking in the
      supernatural darkness of cold-water flats floating across the tops of cities
      contemplating jazz,

      who bared their brains to Heaven under the El and saw Mohammedan angels
      staggering on tenement roofs illuminated,

      who passed through universities with radiant cool eyes hallucinating Arkansas
      and Blake-light tragedy among the scholars of war,

      who were expelled from the academies for crazy & publishing obscene odes on the
      windows of the skull,

      who cowered in unshaven rooms in underwear, burning their money in wastebaskets
      and listening to the Terror through the wall,”

      howl by A. Ginsberg-opening salvo

      Please, stop talking about this, it’s not good for you. It makes us all crazy to see you like this. It’s all over, the law passed. New battles await.
      Sincerely,
      Paul Fernando Tioxon

        1. Paul Tioxon

          That’s right, sometimes, nothing ever good ever happens, to good people, ever, suck it up tough guy.

          1. timbers

            Maybe it’s not all over.

            According to my calculations, ACA give insurance corporations up to $280 billion ($1.3 trillion X 20%) to Citizens Unite us by buying the best Congress and Supreme Court they can (they already own the President).

            So no, it may not be over. That up to $280 billion will be used to “improve” Obamacare for corporations.

            It’s a bright future if your a corporation!

      1. ian

        ” It’s all over, the law passed. New battles await.”

        Fine by me. Implement it exactly then, with no modifications, according to the letter of the law.

      2. HotFlash

        My dear Lambert,
        No matter what they say, do not just sit down and shut up. Your vision is clear, farseeing and impecable.

      3. timbers

        “It’s all over, the law passed.”

        Doubt that is what the insurance corporations plan on doing with the up to $280 billion of our tax dollars they can spend on “improvements” to the ACA.

      4. Oregoncharles

        This is just silly. No law is forever. There is a Congressional election on right now, which will determine control of Congress; there will be a Presidential election a short two years later, which will almost certainly be won by a Republican. (My personal theory is that the major parties have a little deal and just pass it back and forth, two full terms at a time. In other words, the fix is in, and now it’s Obama’s job to make sure the Republican wins next time.) At that point, the results of Obamacare should be increasingly clear, and it will have to be fixed in some way, because it’s already obviously a botch.

        At that point, it will be vital to have a progressive critique available and out there, so we can at least try for something better. Ideally, ’16 will be the year of the political revolution, and we’ll have a chance to fix it properly.

        Fatalism is inexcusable. We have to at least try.

        1. NotTimothyGeithner

          Who will be the GOP candidate? Short of Hillary running against a moderate, isolationist who won’t hold back, Team Blue wins every Kerry state plus Iowa, Ohio, NH (maybe), NM, Colorado, and maybe FL under any circumstance.

          1. Oregoncharles

            I have great confidence in their ability to rig elections, especially as long as it stays 2-Party. If need be, they’ll simply cheat, and tell us all to go hang, as they did in 2000 – the 1st year this deal applied.
            Why do you think Hillary will be the nominee? She has too much negative baggage

      5. Lambert Strether Post author

        IMNSHO — and I did post on this, but am too time-stressed to find it — ObamaCare is the template for future delivery of other services under a market state. ObamaCare is not a “one off.”

        That is, if you want to see a “Retirement Security” website, with Social Security as the “public option” among a welter of financial scams like the 401(k), then by all means consider ObamaCare a “done deal.”

        Me, I would prefer to, as it were, “fight on the beaches,” rather than retreat inland and take what comes.

        * * *

        There is also the issue that the ObamaCare story is exactly what blogs, and blogs like NC, should be covering. Does it not seem remarkable to you that all we know about enrollment is that it’s somewhere in the range of 7 to 13 million? Does it not seem remarkable to you that we don’t even have the most basic aggregation of problems that people may be experiencing with the policies that have been sold? The mainstream media isn’t covering this at all, the left blogs are all in thrall to the Democrats, and the right blogs demand immense effort to filter out the crazy (“death panels”). So who else do you think should cover the story?

        1. human

          Excellent point, Lambert. If we are to accept a government program of this magnitude without meaningful feedback all is lost. Keep on with this exercise in democracy.

      6. hunkerdown

        Shorter: The battle has been settled according to the oligarch’s will, please stop scaring them.

  7. Jim Haygood

    ‘More importantly, if we take Pelosi at her word, is it even possible to determine Congressional intent?’ — Lambert

    A more ontological question is whether a lifeform such as Pelosi is capable of intent.

    Her serene, blank visage brings to mind a Chinese expression, ‘like ducks listening to thunder.’

  8. anonymous123

    Re: narrow networks, I’m actually unsure if the exchange plan physician & hospital networks are *universally* “narrow.” I have some early data on health exchange network breadth vs. commercial and roughly half of payers are reporting that the physician and hospital networks are identical in scope. (Not all though–some payers report their exchange PCP, specialist, and hospital networks being 50% of the size).

    I wonder if the reason we’re hearing so many anecdotes about patients unable to keep their doctor, or find a new one, is due to the issue of doctors not having their contracts 100% settled with insurers for the exchange plans. There was a lot of confusion among payers, physicians, pharma, and other stakeholders around whether new contracts would need to be run for exchanges or whether existing commercial contracts would hold–and thus physicians weren’t sure if they were ‘in network’ for awhile. I think it’s getting slowly ironed out….one reason being that amending physician, hospital, and pharmacy contracts to include another line of business is an administrative behemoth (and most MCOs didn’t get additional headcount to deal with it).

    In any event, I think the issue of network adequacy requires some more investigation to determine whether it’s a “sometimes” or “always” issue.

    1. NotTimothyGeithner

      How many more Friedman Units does ACA need?

      Considering, this is Obama’s domestic accomplishment, and there was 3 years or six Friedman Units between passage and going this excuse is simply unacceptable.

    2. mellon

      >“I wonder if the reason we’re hearing so many anecdotes about patients unable to keep their doctor, or find a new one, is due to the issue of doctors not having their contracts 100% settled with insurers for the exchange plans.”

      anonymous123, thats exactly it, I’m sure. The networks which are available to the ACA “metal plans” are segregated off by contracts which encourage doctors to cross the line into borderline criminal denial of care, (however ERISA Sec. 514 preempts suits) probably (this is my guess but I can’t see how it would be any different) narrow because they only consist only of doctors who are willing to assume the risks of suits (its actually called “risk sharing” ) the risks of denying care, by signing contracts that contain “capitation” agreements and “gag clauses”.

      Have you ever seen one of the newer HMO contracts? No, nobody has, and that is because they are among the most secret of American contracts.

      Capitation got a bad name for itself in the 1990s, but, it never really went away, now its back in force. Basically, doctors get paid a fixed amount per patient and all the patients care comes out of that. Out of the doctor’s vacation funds.

      Gag clauses are really evil, IMO. When the “gag clauses” first appeared in the 1990s they became an issue. Now, my guess is that they are so common they are no longer in the medico-legal literature, however, they are there poisoning the doctor patient relationship.

      To become an in-network doctor, doctors have to agree to withhold not just treatments, they have to agree to withhold even any information about tests or treatments which the HMO has not already agreed- in advance- to pay for. That is a major thing.

      For working people, Ive heard stories that lead me to believe that some people with serious illnesses have been denied tests and diagnoses for months, (also, testing has got major problems in some HMOs-) basically getting the run around, from one doctor to another, when they knew they were sick. I’ve read these very scary stories, especially from California, that imply that the only way people in some networks can get good quality care is to go to some other area, and pretend they are not insured and pay completely out of pocket, in cash.

      But, I doubt if that workaround is still possible, unless people leave the country.

      Contrast the US with Canada, which has nothing even remotely resembling these contracts. Canada makes a best effort to give everybody the best care available (and because of GATS, they must do it for free, so that they wont be “unfairly competing” with for profit firms which would expose the country to risks of a huge investor-state lawsuit.

      In this way they are avoiding the death by a thousand cuts privatization that the NHS is enduring). the US HMOs are trying to lower the legal standard of care in the US by means of these methods. (The US has failed to keep up with other developed countries and its likely the standard of care in the US is actually falling- while in the rest of the developed world its been steadily rising.)

      1. hunkerdown

        There’s a question that’s been on my mind for a good long while that I’ve never seen a very satisfactory answer to: Why would a state submit to an investor-state lawsuit instead of simply disappearing the investors under unfortunate circumstances?

    3. Lune

      Anonymous-
      I’d be interested in seeing your data, and I’d caution you against using payer-reported data. They have an incentive to report the largest possible network.

      I’m a physician so let me give you my own anecdotal experience. When the ACA started coming down the pike, plenty of insurance companies came around and asked us to join. However, the vast majority of them, even the ones that we already had pre-existing contracts with, wanted to pay us medicaid rates for ACA patients. Many contracts with large insurers like Blue Cross, Blue Shield, etc. are separated where they pay a separate and different fee if the patient has Blue Cross private PPO, Blue Cross Medicare Advantage, Blue Cross Medicaid HMO, etc. Therefore, for many of our pre-existing insurance companies, we declined to sign up for the ACA program while continuing with their PPO, Medicare Advantage, etc (sometimes including straight medicaid HMO, which some plans paid better than their ACA plans!).

      At least in California, the insurance companies were caught flat-footed. I guess they just assumed that there were lots of doctors willing to work for free and that they could easily get a network together on the cheap. A few months before the ACA was set to go live, they started coming back with a new tactic. Now, when contract renewals came up, they would demand that physicians accept the whole package (i.e. PPO, Medicare, ACA, etc.) or else nothing would be offered. This got a few more physicians to accept. But lots of physicians who may only get a few PPO patients from any given insurance company, felt it was better to forgo the entire contract than to risk getting flooded with ACA patients paying sub-medicaid rates if you’re the only specialist in town. When insurers saw that they might lose a big chunk of their network (which is one of the main selling points of the real cash cows, their private PPO plans), they usually backed down and renewed the old contracts.

      So now, many of us are in the same boat as before. But depending on the wording of your survey, don’t be surprised if insurance companies are counting physicians in their “network” who refuse to see anyone other than private PPO (or Medicare advantage) patients.

      This doesn’t even get into the question of how many ACA patients a physician is willing to see. For example, plenty of physicians who “don’t take” Medicare patients still participate in Medicare. They just set aside a few appointments a month for new Medicare patients, and backlog the rest.

      At the end of the day, the only data that will matter is looking not at payers and their self-reporting of their networks, but by surveys of patients to see which physicians they were able to see and how much time / hassle it took to get an appointment with them. I’m sure we’ll start seeing these in the next year or two.

  9. sd

    Anecdote: 20 year old relative went online to sign up for Obamacare. Policy choices that were available were more expensive and covered less than current parents policy for dependents so the 20 year old is still covered by parents policy which is not that good to begin with.
    I thought the point was to increase the pool of younger healthier participants instead, the effect seems to be discouraging individual participation.

    1. NotTimothyGeithner

      Obama, let’s ignore motivation, decided to drop a public option, which was part of the platform, and turn the process over to every company out there with no coherent leadership. His numbers were dropping, and he needed to sell ACA. He picked this college aged issue as a means of emotional blackmail, and with cummerbund jobs available to the young, this seemed great. Parents could stop worrying about their kids. It became the Obot story. Now as the 25 year olds have become 26 year olds, the mantra has disappeared. Yes, it very clearly undermines the group pools by pulling healthy donors out of marketplace, but Obama needed a concrete result he understood for the campaign. Obama worries about Obama. Results don’t matter except how they affect him.

      If we accept Obama at his word, his statements from last year’s website demonstrate he has minimal understanding of his policy. Let’s be honest about his campaign, he merely parroted Hillary’s stance two weeks later and dropped the mandate when people started to notice in Iowa and New Hampshire.

      1. mellon

        Neither of them could have worked, I realize that now. Neither Obama’s or Hillary’s both were doomed from the start. There is too much waste. What was it yesterday here, 10 managers(accountants, probably) to every doctor- Most GPs in Europe just have one or two staff members.

        1. NotTimothyGeithner

          They were both hideous, but Obama’s empty suit nature was obvious with no real digging. I voted for him over Hillary among other things because the Clintons were atrocious.

          1. different clue

            Riverdaughter at The Confluence makes a very good case that Obama was by far the vastly much more atrocious than Clinton.

    2. Sammie Sawee

      It does bring in healthier, younger people…just onto employers plans, not market place plans.

  10. impermanence

    When things become this convoluted, then you have to assume the premise is faulty.

    Even under the best of circumstances [a well-funded national healthcare system], this system is severely broken. Only when you can correctly diagnose the illness will you be able to cure the patient.

  11. Lambert Strether Post author

    Just to underline the takeaway:

    If the Democrats can use the nuclear option in 2013 to put some judges on the bench, they could have used the nuclear option in 2009 to pass single payer Medicare for All. It really is that simple.

  12. gardener1

    And some of the most odious provisions of the ACA aren’t even being discussed here. Not only is it not medical care, it specifically provides for all your health information to be available to insidious government agencies like the IRS and the TSA who have no business being permitted to sniff around your health care files. Not to mention the access permissions granted in the bill to other law enforcement and security agencies. Plus you have to turn over all of your financial data to even apply for ACA. This gives governmenty everything from your blood type to your bank balance to browse and abuse as they please. This is a wholesale government takeover of private matters and personal information.

    The ACA also allowed them for the first time, a legal way to tax employment benefits outside of paid wages. The US government has for years tried to pry open the pandora’s box of non-wage benefit taxation. Well here it is. The tax on Cadillac plan health insurance benefits goes into effect in 2016, the final provision of Obamacare scheduled to go into effect only after he leaves office. Brave move O.

    Looking out for the people.

    1. kareninca

      Yes, the ACA is perfectly tailored for the use of the nanny-surveillance blackmail state. My view is that it was created by the NSA, for its own purposes. The Democrats were just the means. And why do you think the Republicans have now stopped trying to repeal it?

    2. different clue

      One major purpose of the Cadillac Plan canard and the persecutionist taxes against employER plans is to tax employERS right OUT of even being able to AFFORD to group-cover their employees. The goal is to force-dump all those covered employees into the Obamacare individual plan exchanges.
      So considering that, among other things, it would do vastly more overall net social good to repeal Obamacare with extreme prejudice than allow it to stand. One more reason why the BigBiz Dems and the BigBiz Repubs will fight like bobcats on meth to prevent any such repeal from ever happening.

  13. Charles Sarno

    What planet do folks live on that the real world alternative to Obamacare over the next five years is going to be better than the current system? Do you think Republican repeal will suddenly lead to a ground swell for single payer? On what basis does one make such a political calculation, given the current political system?

    1. Lambert Strether Post author

      Shorter Charles: TINA, STFU. I leave such calculations to the pros. It’s my job to advocate for the best policy, period. Your job, apparently, is to prevent that.

      1. Charles Sarno

        Not quite sure where you got “TINA,STFU” from my comment, or what that even means. My point is that in advocating for any policy one needs to take political considerations into account. Otherwise it becomes reduced to wishful thinking or, dare I say, mental masturbation.

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