The Destructive Effect of Getting a Permission Slip from the CBO in the Politics of Health Care

By Lambert Strether of Corrente.

The central claim of single payer advocates in the health care battle that culminated in RomneyCare ObamaCare was that the country would save a ginormous amount of money, enough to cover all the uninsured with actual, delivered health care, with no dimunition of service and while actually bending the cost curve down. In 2009, via hipparchia, that ginormous amount was around $359 billion:

[Steffie Woolhandler and David Himmelstein of PNHP] found, in a study published in 2003, that the US spends about 31% of its health care dollars on administration and Canada spends about 16.7% of their health care dollars on administration [this is all administration, not just that attributable to insurance administration]. Which means that we are spending 14.3% of our health care dollars on what is probably useless administration, and they feel that this is a low estimate. Fine-tuning the estimate a little bit yields a difference of about 15.6%.

Since most of Canada’s health care financing is publicly administered and only some of our health care financing is publicly administered [Medicare, Medicaid, etc] and a goodly portion is privately administered [by parasites], they attribute this extra 15+% to the blood-sucking leeches health insurance industry.

So, now we can do a little simple arithmetic. In 2007, our total national health expenditure was estimated to be $2.24 trillion; 15.6% of that would be $349 billion [that’s close enough to $350 billion for me]. The forecast NHE for 2009 is roughly $2.5-2.6 trillion; 15.6% of that would be $390-405 billion, which is why you’ll sometimes see people, Bernie Sanders for one, saying we could save $400 billion if we just dump the private insurance companies.

Updating this to the present day, using similar reasoning:

Upgrading the nation’s Medicare program and expanding it to cover people of all ages would yield more than a half-trillion dollars in efficiency savings in its first year of operation, enough to pay for high-quality, comprehensive health benefits for all residents of the United States at a lower cost to most individuals, families and businesses.

That’s the chief finding of a new fiscal study by Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst. There would even be money left over to help pay down the national debt, he said.

Assuming paying down the national debt to be important, which it may, or may not be, given the state of the real economy. (More below on that.)

Friedman says his analysis shows that a nonprofit single-payer system based on the principles of the Expanded and Improved Medicare for All Act, H.R. 676, introduced by Rep. John Conyers Jr., D-Mich., and co-sponsored by 45 other lawmakers, would save an estimated $592 billion in 2014. That would be more than enough to cover all 44 million people the government estimates will be uninsured in that year and to upgrade benefits for everyone else.

“No other plan can achieve this magnitude of savings on health care,” Friedman said.

So, $359 billion in 2009, $500 billion in 2013, either way, you’re talking real money (and, more importantly, massive misallocation of resources in the real economy). Unfortunately, the CBO scoring models used in the ObamaCare debates only measured government revenues and spending; they did not measure benefits, society-wide, to the American people as a whole. Therefore, single payer’s ginormous savings were taken “off the table” throughout the debate, a priori. It’s as if — assuming here that government is like a household, which it isn’t — the head of the household refuses to lay out one dollar of the ten they have in their wallet, because they’d end up with nine, even though the family, as a whole, might gain a thousand dollars if that one dollar were spent. As Bloomberg explained at the time:

In his post, the [CBO’s] 47-year-old [Douglas] Elmendorf is the official scorekeeper on Capitol Hill for the cost of health-care proposals.

Elmendorf’s agency provides the final word on the price of a government insurance plan, the savings from fighting obesity and whether a bill fulfills Obama’s pledge to expand health-care coverage and cut costs without raising the budget deficit.

With a federal budget deficit the administration projects at $1.8 trillion this year, paying for broader health coverage is central to a bill’s prospects. Budget rules require lawmakers to use the nonpartisan CBO’s cost estimates unless Congress takes extraordinary steps — such as a supermajority Senate vote — to ignore them.

So, “not increase the deficit” is that dollar bill the Bad Dad keeps in his wallet, even though spending it would win his whole family $359 (or $500) billion. What would have been needed — rather, what would have been done, had the Democratic effort on health care “reform” had a shred of intellectual honesty, heck, common human decency — would have been not CBO scoring, but a full analytical study. Health care regular SteveB at Daily Kos in 2009 (cleaned up just a touch):

“Scoring” is a narrow and limited process that deals only with bills that are moving through the congressional process and only looks at Federal cost, which would show a tax increase for single payer, but ignores savings for total U.S. and all other stakeholders.

The CBO study we desire should have been requested back in January before the congressional process became locked in on particular legislative approaches.

Missed opportunity, to say the least. And not merely by career “progressives” too bsuy running interference for Obama, but by legislators with single payer bills they’d actually introduced; Conyers (HR 676) and Sanders (S703).

It’s very important to use the correct language. We want an “analytic study” and we do not want just “scoring.’ Do not use the word scoring. Scoring only looks at the federal budget piece, which of course goes up under single payer. Only an “analytic study” can look at the total costs, and costs to different sectors (federal, state, local, individual tax, individual premium, individual out-pocket, employer, etc.).

The ask should be:

“There ought to be a complete, honest, side-by-side comparison of all proposals, including single payer, as a complete analytic study by the Congressional Budget Office &/or the Geneal Accounting Office. [T]he side-by-side comparison should include not only the Federal government costs, but also the projected total U.S. cost and the costs to other stakeholders including state and local governments, employers and to individual, families and households of different income levels.”

Still true today! (The author provides a “model study” by the Commonwealth Fund.)

Chris Hayes, bless his heart, got the politics right back in 2009:

[C]onverting a moral and political argument into a technical and accounting one ends up ceding veto power to the accountants at the Congressional Budget Office. In a Beltway version of Revenge of the Nerds, every time a Democratic bill comes out of committee it’s sent to the CBO to be “scored”–that is, to evaluate how much it will cost and how much it will “bend the curve” on future costs.

That’s the “permission slip” part.

So far, the results have been mixed. CBO head Doug Elmendorf has been skeptical about the gains to be had from measures like health IT and wellness programs, and both the House and Senate [ObamaCare] bills have been scored as revenue neutral over the next ten years. In another context that would be great news, but since healthcare is being sold as a way to reduce the deficit, revenue neutral doesn’t quite cut it.

And Hayes got the semantics part right, too:

The other problem is broader than just these pieces of legislation. Obama has inherited a shared political vocabulary in Washington (with phrases like “fiscal discipline,” which he himself employs) that shapes the contours of the possible and semantically militates against progressive politics at every invocation. If “fiscal discipline” meant that politicians support tax increases on the wealthy or cuts to the military budget to pay for programs, it would be a useful concept. But what “fiscal discipline” means in Washington is cutting government. It means no taxing and no spending. It means “pain” and “sacrifice” and gutting the welfare state. When politicians say they’re “fiscally conservative,” what it actually means is they’re conservative. Full stop.

Today, in 2015, we understand the politics, the semantics, and — thanks to MMT — the economics. From Joe Guinan of Renewal:

The notion of a revenue-constrained government budget in a monetarily sovereign state may be a useful fiction for conservatives and rentier capitalists, but it should not have gone unchallenged by the left. As a result, any proposal for investing in social provision, or even in efforts to prevent climate change-driven civilisational collapse, runs immediately into the killer question: ‘How are you going to pay for it?’ (Mosler, 2010, 13).

As we have just seen in the policy-making debacle of ObamaCare, the Democratic answer to that question, fully compliant with that “useful fiction,” shamefully lost and is losing thousands of lives. A killer question indeed!

* * *

So, if you want to make decisions from the standpoint of — to strike a blow at random, here — “provid[ing] for the general welfare of the United States” (U.S. Constitution, Article I, Section 8), demanding “revenue neutrality” as determined by CBO scoring would clearly be insane. So the Republicans aren’t all that nutty to insist on dynamic scoring, which at least attempts to take their whacky views of “the general welfare” into account. It’s only that their ludicrously tendentious methodology — the faith-based Laffer Curve — gives the impression of right-bending ideological rigidity so acute that only the political equivalent of an orthopedic appliance could cure it. If only a better methodology were available!

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. bkrasting

    I agree with Lambert when he concludes that CBO’s review of ACA was done with blinders on. To look at the consequences of any new law one has to look outside of the narrow consequences to the Federal Government and consider the overall results to the economy and society.

    I agree with Lambert that if the CBO had truly looked at healthcare in 2009 it probably would have considered a single payer system to be a better system than what we got.

    If the CBO had done its job in 2009 it’s likely that ACA would not exist today, and its possible that we could have something closer to a single payer system. – So an opportunity was wasted and bad choices were made.

    I also agree with Lambert’s conclusion, ” the Republicans aren’t all that nutty to insist on dynamic scoring”.

    Lambert and I don’t agree on what are the consequences to the broad economy of changes to tax policy. But we do agree that the consequences can’t be measured by the narrow view on government deficits. The results to the broader economy and the welfare of the citizens have to be taken into consideration, just as in the case of Single Payer vs ACA.

    The way things are looked at in D.C. (by CBO and others) favor bad results. Choices are made without consideration of all the alternative choices/consequences. All significant legislation should be ‘dynamically scored’, whether it be healthcare or taxes. Society would be better off in the long run. So Lambert is right – However It does create a bit of a conflict with the editorial board at NC……..

  2. scott

    But…$350 billion a year divided by $100K/job is 3.5 million jobs! What are these people going to do?

    1. Sam Adams

      Poop clean-up and bed pan duty.
      Obama told us big pharma and insurance companies were ‘merican’s friends

    2. Lambert Strether Post author

      To answer the distraction from the CBO:

      HR676 provided for transition assistance; there is certainly real work to be done in the health care field, instead of paper-pushing with a view to denying people care; and much of this work involves specialized medical coding and EHR. Right now, the coding is optimized for the purposes of insurance company rental extraction; it could be repurposed to actually assist with the delivery of services. Finally, this is a fine argument for a Jobs Guarantee, the generic solution for “transition assistance.”

    3. paulmeli

      “But…$350 billion a year divided by $100K/job is 3.5 million jobs! What are these people going to do?”

      Employ more people in the healthcare system With the $350B instead of the insurance industry. The federal budget doesn’t get cut…every year the budget gets bigger, averaging a 7% increase annually since WWII (nominal).

    1. Verne

      Considerations of cost are not entirely without some relevancy. Enough money to cover everyone yes, I agree, it is there. But, cost inefficiencies in running a business, and then charged to the customer (Federal Central Bank) are never a good thing, no matter how the bill is paid. Cost overruns (by comparison with other countries) show that something is wrong with the system and that means the consumer (patient) may be harmed. We are talking about medical care so if the quality of care is low (true ’nuff in America-and elsewhere) then that will show up on increased costs.

  3. Jim Haygood

    In our current accidental system, the half of US medical care that’s still private (and profitable) subsidizes Medicare (at cost) and Medicaid (below cost) services, via legalized price discrimination.

    ‘Medicare for all’ would be obliged to raise Medicare reimbursements significantly to replace the lost revenues from profitable private care.

    This is not to deny that there might well be administrative savings. But Medicare at current reimbursement levels cannot be extended to all without bankrupting hospitals and inducing physicians to down tools and walk.

    1. Lambert Strether

      I take it, then, that you support the these of the post? Were these assertions to be true, the full analytical study (as opposed to mere “scoring”) would show that.

    2. ambrit

      “..inducing physicians to down tools and walk.”
      Walk to where? Canada? Mexico? Kazakhstan?
      Why not remove some of the reasons new physicians need so much money? Have a student loan jubilee if they work for cheap in public hospitals for three years. (Many already do this during their internship period. And the beneficiaries are the often the University affiliated hospitals they intern in.) Work out some social status method similar to what Germany does?

    3. hunkerdown

      They’re already walkinginto Canada, and in part because dealing with private insurers on the back end sucks less than dealing with state treasurers, who would never leave payables go for more than a year, unlike some USian claims management firms.

      1. bruno marr


        My cardiologist dropped his group practice ,which was taking 40% of his income in administrative fees, and now sees mostly Medicare patients. He tells me he’s making more money, is providing better care, and enjoys his medical practice/life much better. (He’s not stupid; Phi Beta Kappa Univ. San Francisco Medical School and Harvard University.)

  4. flora

    CBO scoring for revenue neutrality is meaningless without cost controls. Pharma and insurance, afaik, have no meaningful cost controls imposed by O-care. Single-payer would make cost/price control much more likely. Single-payer was taken off the table by Obama.

    from a Salon article about the Dems falling for GOP framing of issues:
    “To avoid such predatory pricing, merit-good industries with monopoly/oligopoly structure should be price-regulated utilities under public or private ownership. In the New Deal era, public utility regulation was extended to electricity and water service, telephone service (the regulated AT&T monopoly, in which the rich and business cross-subsidized middle-class phone use), and the tightly regulated banking industry.

    “The greatest mistake of the Great Society legislation of the 1960s was expanding federal subsidies to health care and higher education, without at the same time converting higher education and medicine into price-regulated public utilities. The predictable result was an explosion of college costs and medical costs, as predatory providers used the market power of their concentrated industries to extract rents or excess payments from taxpayers and private purchasers alike. No similar cost explosions occurred in countries that controlled higher education prices as well as the prices that can be charged by drug companies, hospitals and physicians.
    “In other words, unlike New Deal utility regulation, the Great Society reforms of the 1960s–student loans, Medicare and Medicaid–inadvertently encouraged price-gouging….”

  5. Eureka Springs

    An additional option on the table should include CBO scoring and a full analytical study of expanded V.A. / tri-care for all as well.

  6. flora

    I had a longer comment vanish.
    Shorter: without single-payer negotiating meaningful price controls on Pharma, hospitals, etc, the CBO scoring is a meaningless exercise that does nothing to prevent price gouging by, essentially, monopoly providers.

  7. MartyH

    Thanks, Lambert. The whole notion of some group of technocrats (bureaucrats, politicrats) “scoring” legislation according to some probably wrong-headed economic theory is bonkers. To design the consolidated control over the medical, pharmaceutical, and health-related bankster insurance industries to optimize such a “score” is, to quote someone I recently read, like “step-dancing until Mom’s cancer is cured.”

    Two of my own observations. First, left to a well-captured Congress (government as a whole) why would we expect any outcome other than that optimized for those special interests wielding the power of the check-book. Second, as I am mistrustful of consolidated power (The One … To Rule Them All, so to speak), why would I look to consolidation of price-power in a Single Payer system to eliminate capture (in some other and unpredicted way)?

    1. Bill Frank

      Your concern correctly identifies the underlying problem that literally prevents progress on virtually every issue, including healthcare. Our government is “captured” and it will only serve the captors as they desire. Lambert’s piece is well-done, as are many, many others on NC, but the most urgent, and difficult question is how do we take back our government. This is the core challenge of our time.

      1. diptherio

        We need to re-instill direct democracy at the party level. We now have the tools available to realize a system wherein a representative’s votes in congress could be decided by the representative’s constituents using something along the lines of Loomio:

        So, imho, we need to create a party whose sole platform is that the elected rep will vote only inline with the will of the constituents, as expressed by their votes on the on-line platform. That’s the bare bones. It requires much fleshing out, of course, but that’s the basic direction we should be setting our sights, if you ask me.

        1. bdy1

          What, the Senate, congressional calendar and 2 month presidential lame ducks don’t suit you? The whole setup is perfectly tuned to the pre-steamboat, pre-pony-express transportation and communication grids . . . with new-fangled Diebold ensuring careful counting and MSNBC monitoring accountability what could possibly go wrong?

  8. as

    If we got rid of the contingency legal system and had loser pays as in England we would save a comparable amount. It is not just malpractice that triggers overtesting and overtreatment. The use of the medical system to justify benefits for those without jobs….disability or to justify huge personal injury settlements (see the recent NYT article on mesothelioma) when the settlements are based on high medical costs which the legal profession pushes are a huge part of the cost structure. For example, 40% of the cost of California worker’s comp is for back surgery that does not work and that is just one small part of the useless treatment Americans want and receive. It is billions of dollars nationwide. This sort of medical fraud is rampant and encouraged by the lawyers and the patients because more treatment means more settlement.

  9. LizinOregon

    Lambert gets to the heart of the issue here. CBO does not generate it’s own work. It provides cost estimates for legislation as mandated under the Budget Act and those estimates only include the impact on the federal budget and state and local budgets. And it does analysis of the impact on the wider economy when requested by members of Congress. Conyers and Sanders could have requested such a study but apparently did not. CBO also includes these broader impacts in the calculation of their annual baseline after a law is passed, but those impacts are rarely identifiable as related to a specific bill.

    As happened with the Clinton health insurance plan, when major programs are considered CBO’s very narrow numbers (narrow by law) are used as ammunition in the debate by whichever side they favor. In the Clinton case CBO determined that it should be included as part of the federal budget when the White House argued it all happened outside of government spending. To this day the Clintons blame CBO for that failure but it is really a political failure. I guess what I am saying is that in the end the CBO cost estimate really doesn’t matter if there is the political will to pass the legislation.

    Does that make me an MMT’er :^)

    1. financial matters

      Yes. :). I see it as political (social), economic (money, mmt). Right now we have economic running political (market rules), we could have political running economic. But most MMT people aren’t satisfied with just describing how the government actually spends. They would like people to understand that in order to better understand their options. And you also see them advocating representative democracy.

      1. LizinOregon

        Yes, we must understand the system before we can change it, which is why most of us read NC. CBO is a handy scapegoat for politicians to hide behind and that often gives their analysis more weight than it deserves in the policy debate. The reality is they are an accounting function that cowards use to justify their inaction. My hope would be that some day we come to view all economists that way.

  10. dogpajamas


    First time commenter here so be gentle. While I do favor a single payer system and agree with many of your points, I feel like trying to quantify the system’s benefit to society through the CBO is problematic at best. Wouldn’t this be much like the GOP sponsored “dynamic scoring” evaluation criteria?

    As salient as these points are, they would be rendered useless if introduced into an evaluation that favored the supply side of things. Furthermore, I feel like there would be plenty of ways in which a supply sided examination would side heavily with the private insurers and not the public at large.

    From your perspective, what would be the best way to measure a program’s societal benefit without having it become subject to some fallacious neoliberal standard?

    1. Lambert Strether Post author

      Well, you’ve got to start assaulting neo-liberal assumptions somehow, somewhere, and probably win the day with personnel changes. An excellent place to begin the assault would be the CBO. This post is a small start in that direction. There will probably be others making the same point, better.

  11. KenG

    Two questions:

    1) Do you think more Americans are better off today, with respect to health care? Not is this the best way to do it, but do you think more Americans now have some kind of health care besides going to emergency rooms and not paying for it? (that’s still just one question).

    2)If you could go back to 2009, what kind of health care plan do you think you could get passed, knowing that you would not get any Republicans in the house to vote for it, and could not afford even one Democratic senator to go along with a filibuster? So you would have to keep all of the congressmen who just took over Republican seats, and keep every Democratic senator, including all of the ones from red states, happy. What do you think you could have passed? What did Obama leave on the table?

    1. Yves Smith

      Lambert can answer 1 better than I can. While some people have been helped by Obamacare, mainly through Medicaid expansion, many have been hurt or gotten a headfake. For instance, I spoke at length with someone whose wife had a pre-existing condition, and he said it was a wash between being insured and not insured (as in the premiums deductibles were so high under Obamacare as to make the insurance not all that useful). And we have the big problem that if you have a costly condition, you have no control over who is put on your surgical/hospital team, and hospitals have a nasty way of putting out of plan doctors on the bill so as to loot from the patient. So the “insurance” is a lemon product.

      In 2009, the country was prostrated by the crisis, desperate for leadership, and the Dems had majorities in both houses. Obama could have gotten single payer passed. He didn’t want it. He left everything on the table, by design.

      1. KenG

        Maybe, in 2009, he could have forced single payer through Congress, but I’m not convinced. Yes, they had 60 Democrats in the Senate, but they weren’t all in favor of single payer. They needed all 60 votes to avoid a filibuster. Teddy Kennedy died that summer, and the Democrats lost their filibuster-proof majority in January (I was just reading that one of the reasons Scott Brown was able to upset the Democratic candidate was unhappiness in Massachusetts over the health care bill. They thought it was too much. In Massachusetts. Selling this to all Democrats was not going to be easy if it didn’t go over well there.).

        Maybe a more experienced President Obama would have been able to impose his will upon his party, but he had only been president for a short time, having just moved up from being in the senate for only four years. He did not have a hammer in the House or Senate, like his predecessor did.

        I don’t have a great memory of the debate in 2009 over health care, mainly because I, like a lot of other people, was focused on the cratered economy and crippled financial system. I don’t recall that support for what would have effectively been nationalized health care being very broad and deep throughout the nation. Obama’s left-wing supporters certainly wanted it, but the party was not that united, and easily divided by Republicans, who won back the house mainly because of opposition to the watered down bill that did pass.

        In any case, the health care system, with or without the ACA, was/is a sinking Titanic, and now we’re not even re-arranging the deck chairs, we’re just talking about how the deck chairs were badly re-arranged (as if that would prevent it from sinking), and how mad that makes us, and not talking about how we can improve it. I don’t hear any suggestions on what to do, other than to undo it. If this is bad for so many people, and so expensive, then it should be politically easy to reverse it. Reversing it won’t address the reason for why it was done in the first place, but obviously those in favor of getting rid of it don’t care about the people it has benefited.

          1. KenG

            So you’re saying he could have forced Harry Reid to invoke the nuclear option in 2009? I doubt it.That would have been the end of the filibuster, and nobody seems to want to do that.

            1. katiebird

              The filibuster didn’t come into it at all. As Lambert said in the comment you replied to, “ObamaCare was ultimately passed, with a bare majority, with reconciliation” — there were no Republican votes and in fact not all the Dems voted for it.

              But, I’ll go even farther. When Obama took office he was in a position of great power. It’s my belief that if he had gone even once down to Congress to KNOCK HEADS he could have gotten any legislation he pleased passed in those first 100 Days of 2009. But he didn’t.

              He sat around in the White House (taking time out to fly around accepting Nobel Prizes) and didn’t use that power to pass the sort of bills that could have helped us.

              Do you really think the so called Blue Dog Democrats would have stood up to a Dem President with a Cause? I don’t. I think we could have had a stimulus that mattered, we could have had universal healthcare for everyone, we could have seen bankers lined up in orange jump suits — we could have seen it all. Even an end to the wars.

              But instead we got the myth that without 61 votes, a Democratic president was totally helpless against the overwhelming power of a couple of naysayers (see J. Lieberman)

              1. KenG

                “Do you really think the so called Blue Dog Democrats would have stood up to a Dem President with a Cause? ”

                Absolutely. They did it until they were knocked out of office.

                Maybe he could have gotten anything passed those first 100 days, but anything that would have been rushed would have been full of holes and errors. Not intentionally, but because that’s the nature of people. And I don’t know that he knew exactly how to wield that power so quickly, nor do I think anyone who has only been a junior senator for 4 years would so quickly grasp the possibilities. his predecessor didn’t figure it out himself, he did the bidding of guys like Cheney and Rove. And Clinton, the great negotiator, failed at health care so badly in his first few years that it almost cost him a second term.

                Is Obama a great president? No, but tell me who was in the last 50 or 60 years. I’d say he is the best we’ve had (and I can complain about mistakes he has made that are far more damaging than ACA) in my lifetime. I think criticism of this program is fair and warranted, but using it to completely reject him is absurd..

                1. katiebird

                  The bills – in both the House and Senate – for universal healthcare for everyone already existed and had for years. Nothing rushed about them. In fact, they’re pretty simple and they could both be read in a single sitting.

                  Why do people like you believe that elections don’t matter? No party has had as much power since the post Watergate elections. Obama and the Dems had HUGE majorities.

                  They’re failure to pass the legislation we needed was their choice.

                  1. KenG

                    In 2009 I would not want a bill that was written in 1993 to be passed without changes. There was no web then, and politicians’ understanding of how the Internet works was even more pathetic than it is today. The health care system, and the financial system (not to mention the economy) were not in the same condition they were in years earlier. And I think you overestimate the chances of passing any bill that modifies a complex system like health care insurance, without amendments to a 15-year old plan.

                    I never said that elections don’t matter, and I don’t believe that. You act as if the Democratic party in 2009 was this big united group of progressives with a consensus on how to undo W’s damage. I think how they have acted proves that was far from the case.

                    1. Lambert Strether Post author

                      I understand your wants but not your reasoning. The beauty of single payer is that it’s simple; HR676 is all of thirty pages, not however many thousands of pages long ObamaCare was. When you’ve got a simple, rugged, and proven solution, you don’t have on the lookout for the latest bell or whistle.

                      Further, HR6767 and S703 were both re-introduced in 2009; I’m sure they were kept up to date

              2. KenG

                Further, about those yellow dog democrats, how do you think the Republicans took back the Senate last year? They knocked out the Democrats who rode Obama’s coattails into office in 2008. And those Democrats lost mostly because of ACA (and fears of Ebola and ISIS). They thought the plan that passed was socialist, what do you think would have happened if they actually passed single payer?

                1. Lambert Strether Post author

                  This may be a new idea to you, but yes, it’s possible to change the terms of debate and deliver concrete material benefits to voters. Had both been done, the Democrats would have been in better shape in 2010, and in 2014 as well.

              3. Vatch

                When Obama took office he was in a position of great power.

                Correct. The Democrats had significant majorities in both the House of Representatives and the Senate. The number of Democratic Senators varied during the 111th Congress from 55 to 58 out of 100, always with an additional 2 independent Senators who caucused with the Democrats. The number of Democrats in the House ranged from 253 to 258 out of a total of 435. Obama could have been another FDR, but that’s apparently not what he wanted.

            2. Lambert Strether Post author

              If saving American lives and a ton of money were the goal, then the process issue of the filibuster would be a lesser priority. Further, as Katiebird points out, the Rube Goldberg device that is ObamaCare passed with a bare majority anyhow. So why not work for the right policy from the get go?

            3. Lambert Strether Post author

              Shorter: “The President is not a dictator,” a 2009 Obot talking point.

              What you’re really saying is that when Democrats control the House, Senate, and the Presidency, and when the greatest orator of our time has a mandate for “hope and change,” and when the Republican party is completely discredited, that nothing of real substance can be done, and hence (for example) the only option is to pass a health care plan originated at the Heritage Foundation to head off single payer, and first implemented by a Republican.

              If what you say about Democrats is true, surely you agree they should go the way of the Whigs?

    2. Jeff W

      do you think more Americans now have some kind of health care besides going to emergency rooms and not paying for it?

      Well, we know for sure they now have some kind of health insurance—which might or might not cover their health care.

      Here’sTrudy Lieberman of the Columbia Journalism Review in 2013:

      The insurers’ game is to grab as much market share as possible, as fast as possible. To do that, they need to entice customers with low premiums. The White House euphemistically calls low-cost policies “more efficient”—words that tend to obscure the trade-offs and choices that shoppers will have to make.

      A low premium means that a consumer may have to take a policy that requires high deductibles, high coinsurance (a percentage of a bill they have to pay), or high copayments (a set amount for a particular service). Shoppers in the exchanges will also have to make other trade-offs depending on the strategies insurers use to fashion a premium that sells in the marketplace.

      One strategy some carriers are considering is a narrow network of providers; in other words, fewer choices of doctors and hospitals.

      [emphasis added]

      High deductibles, high coinsurance, high copayments—on top of their premiums—along with narrow networks. (With exclusive-provider organization [EPO] plans, patients generally have to pay full charges out-of-network.) And, making the generous assumption that people can figure out the policies, there are issues of misleading statements/failure to disclose regarding coverage. (Putting out-of-plan doctors on the bill, as Yves says, is an additional issue.) It’s sort of a obstacle course, if not a minefield, of health insurance. How many people with insurance will be unable to pay their bills, struggle to pay their bills, forgo treatment because they fear not being able to pay their bills or not take their medication as prescribed?

      1. KenG

        There are still millions of people who now have something rather than nothing. Ask them if they are happy. Or do they not matter?

        The health insurance system sucks. But for some, less than it used to. I don’t understand why so many people think Obama is the worst president ever because he didn’t fix this system. As if the rest of the industries in the U.S. are so efficiently and fairly managed.

        1. Lambert Strether Post author

          As I keep saying, a program of ObamCare’s scale was bound to benefit some people. However, it does not and cannot benefit all, equally.

          Frankly, it baffles me that the “It benefits some people!” seem to think that’s enough. Guess it goes with throwing people under the bus, something that the Democrats in general, and Obots and the Obama administration in particular, are past masters at.

          I want all to have access to health care, equally, to save the lives of people who would otherwise die. You don’t. I guess that’s the difference between us.

      1. KenG

        Yes, that set the bar low. But we’re talking about politicians here, people who mostly want to solve political problems, not real problems. Show me a presidential candidate who isn’t a politician, and I’ll show you someone who won’t even get the nomination.

        The alternative was nothing. The bar is higher than it was. The alternative today is still nothing.

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