By Lambert Strether of Corrente.
In my previous post on the public option, readers commented that they liked having the history of the so-called “public option” consolidated all in one place, so they could refer to it, and refer others to it.
I’m guessing that after Labor Day, ObamaCare will become more prominent in the narrative; this year’s “open enrollment” period begins on November 1, a week before election day, and it’s likely that sticker shock and the general crapification of the policies will become an issue of public concern (or at least an excuse for another public relations exercise by the administration). In addition, the slow death spiral of the exchanges may lead to calls for Congress to “do something,” in the lame duck session; perhaps even introduce legislation for the “public option.” Finally, Sanders has supported Colorado’s single payer initiative, in open conflict with Clinton’s “never, ever” position. So ObamaCare is coming up on the charts once more.
So I thought I’d take a stroll down memory lane and consolidate links to posts in Naked Capitalism’s rather large corpus of ObamaCare-related material. (There are — let me check — over 100 on ObamaCare, and over 300 on health care policy, and that’s too many to list, so I’ll be somewhat selective.)
I put the posts into the following categories:
- ObamaCare and “Estate Recovery”
- The ObamaCare Website Launch Debacle
- ObamaCare’s Narrow Networks, and Health Insurer Gaming
- ObamaCare’s Lack of Universality
- ObamaCare’s Neoliberal Foundations
- ObamaCare vs. Single Payer
- ObamaCare and the So-Called “Public Option”
- ObamaCare’s Death Spiral
- ObamaCare Enrollment (and Gaming the Numbers)
- ObamaCare and Public Relations
- ObamaCare Crapification (General)
- ObamaCare as a Tax on Time
Each category is numbered. Each post within each category is lettered, so references to individual posts can always be crystal clear. For example, “How Obamacare Raids the Assets of Low-Income Older Americans” is #1a. I’ve added a brief commentary — each very counter-intuitive to the official view — before the posts in each category.
I hope this listing will be helpful to you as you combat bullshit and bafflegab in the forthcoming health care policy debate.
Readers will recall that Medicaid has a policy called “Estate Recovery,” whereby the costs of heatlh care for people over 55 and under 65 under Medicaid are “clawed back” from their estates. This means that a poor person whose sole remaining asset is their house may be unable to pass the family home on to their children. This makes ObamaCare’s mandate especially immoral, because it forces people into the Medicaid program based solely on income. So, if you’re over 55 and poor, you face the Sophie’s choice of putting your health care at risk by “going naked” and not signing up at all, and screwing your children. As you see, we drew attention to this problem in 2014; it still exists (see Minnesota, Iowa, Massachusetts, and California, where hilariously a law that makes state clawbacks only as draconian as the Federal clawback policy mandates is presented as a tremendous victory).
I place this relatively minor matter — minor, that is, unless you are poor and over 55 — first because it proves that just because you aren’t seeing stories in the press about one of ObamaCare’s many problems, you should not assume that the problem has been solved; rather, you should assume that the problem still exists, and has become a non-story. The flip side of Adam Smith’s saying that “There is a great deal of ruin in a nation” is that “People can adapt to a great deal of crapification.” They get used to the insanity, feel themselves powerless to change it, and make the best of what they have. (Clintonian excrementalism is based on a cynical and corrupt but sound view of how elites can manage non-elites successfully.)
- 2/11/2014: How Obamacare Raids the Assets of Low-Income Older Americans
- 2/17/2014: Consumer Reports Shills for ObamaCare, Pooh-Poohs Medicaid Clawbacks on Bizarre Assumption They’ll be Waived
The ObamaCare launch was a case study in botched project management followed by executive impunity for the debacle. Medicare, back in the days of steam-driven computing and punch cards, was rolled out in a year. ObamaCare was passed in 2010, and by May of 2013 it was clear to the discerning that the project was in deep trouble, which the White House had just compounded by changing the applications form as a public relations effort to reduce perceived complexity, requiring significant recoding by some ObamaCare exchanges.
In July, alert reader Katiebird and I began to look at ways to help future ObamaCare applicants fill out their forms, and it was evident that material we would expect an on-time project to have developed simply didn’t exist (“A Secretive Project Out of Control”).
As ObamaCare staggered toward the finish line, it became evident that not just the “front end” — the website where users would apply for the policy — was in trouble, but the back-end — the systems that transmitted the user’s selection of a policy on the front end to the insurance companies — was also in trouble. Then came the actual rollout, where the website — not having been tested under load — crashed, and had terrible user interface/user experience characteristics if and when it worked. Ultimately, a tech team from Silicon Valley was brought in to fix what ObamaCare’s project management team at HHS, and its government contractors had wrought, and the front end was fixed. Problems on the back end were not fixed.
Naturally, no heads rolled, whether at HHS or in the White House. Apparently, nobody in the White House chain-of-command had the stones to bring the oncoming debacle to Obama’s attention, and/or he was lying about how terrific the system was until just before launch. (If you have the stomach for it, you can read the two color-coded transcripts for a good sense of Obama’s bafflegab, bullshit, and outright lying on this sordid tale.)
- 5/7/2013: Obama’s April 30 Presser on the ObamaCare “Train Wreck” (color-coded transcript)
- 7/8/2013: ObamaCare Rollout: Punts on Income Verification and Employer Insurance Checks, Setting Stage for Insurers to Call Mistakes “Fraud” and Rescind Policies
- 7/17/2013: ObamaCare Rollout: Will the All the State Exchanges Launch on Time? A Secretive Project Out of Control
- 8/25/2013: ObamaCare Staggers Toward the October 1 Finish Line
- 8/30/2013: ObamaCare Staggers Toward the October 1 Finish Line (2)
- 9/8/2013: ObamaCare Staggers Toward the October 1 Finish Line (3)
- 9/9/2013: ObamaCare Staggers Toward the October 1 Finish Line (4)
- 9/16/2013: ObamaCare Staggers Toward the October 1 Finish Line (5)
- 9/26/2013: ObamaCare Staggers Toward the October 1 Finish Line (6)
- 10/7/2013: ObamaCare Launch: First Hints of Real Back-End Problems on the Federal Exchange Begin to Appear
- 10/18/2013: Obamacare Rollout: Will Insurers Be Hoist on the Enrollment Petard?
- 11/30/2013: Michael Olenick: How My Experience with Healthcare.gov Shows “Better” Software May Not Be the Solution
- 10/23/2013: Obama’s Remarks on the ACA Rollout Debacle: From Selling Hope and Change to Hawking Insurance (color-coded transcript)
- 11/11/2013: The ObamaCare Rollout, Organizational Dysfunction, and Public Relations in the Administration
- 12/2/2013: Obama Kept His Head in the Sand During Healthcare.gov Fiasco
- 12/23/2013: America’s Shopper-in-Chief Has His Staff Sign Him Up for ObamaCare (But Not His Family)
- 8/7/2014: ObamaCare and Executive Impunity
- 9/24/2014: With Two Months Until Open Enrollment, ObamaCare’s IT Is Still a Hot Mess
3. ObamaCare’s Narrow Networks, and Health Insurer Gaming
ObamaCare imposes various requirements on the health insurance companies, including (and a good thing, too) the requirement to cover people with pre-existing conditions. However, the health insurance companies are profit-driven, and so they very naturally have methods to make up for those lost profits in other ways, in essence by denying people care, or refusing to cover services performed. Prominent among these methods are “narrow networks” (and narrow pharmaceutical formularies), which can be optimized by zip code and provider to exclude sick populations who might actually file claims. Prominent also are high deductibles and lousy coverage, as Naked Capitalism readers discovered and documented when they actually applied for policies. Other prominent barriers to care include the complexity of the policies themselves, inaccurate registries, lack of primary care doctors, and the difficulties of comparing plans when policies are purchased.
- 10/12/2013: Obamacare Narrow Networks: How They Affect Doctor Specialties
- 11/12/2013: Michael Olenick: Comprehensive Review of ObamaCare Plans Reveals Not Only High Cost for Atrocious Coverage, but Also Apparent Violations of ACA Requirements
- 2/29/2014: ObamaCare: “Per Beneficiary” Limits a Loophole Insurance Companies Can Drive a Truck Through?
- 10/2/2015: ObamaCare’s Narrow Networks, and Who To Blame When “There Is No Alternative”
- 3/25/2014: ObamaCare Discriminates Against Poor People with Cancer (and Obama’s Lying Again)
- 5/1/2014: ObamaCare Clusterfuck: “Medical Homelessness” in California
ObamaCare has any number of misfeatures, most of which are functions of its basic system design: The requirement for “eligibility” (as opposed to single payer’s philosophy of “everybody in, nobody out”). ObamaCare’s complex eligibility requirements mean that coverage (and hence the actual care that you, as a
consumer citizen will receive) is random with respect to jurisdiction, class, and age. In no particular order: If you are a citizen of Libby, Montana (in ObamaCare architect Max Baucus’s district) you instantly got single payer. If you are unbanked, you could be out of luck. If you’re a Congressional lawmaker or aide, you get better treatment than the rest of us. If Enroll America decided to market to you, you are more likely to have coverage than those who were left out of that effort (and who do you think Enroll America marketed to? The sick? Kidding, right?) If your identity data at credit reporting bureaus is messed up, you could have trouble registering. If you’re in a state that didn’t expand Medicaid, you might not get coverage at all. Prices and policies vary by geography. Prices and policies vary by jurisdiction, down to the county level. If you’re a seasonal or contract worker, you can gain or lose your coverage based on “major life events.” If you work in the informal economy, you might not be able to prove your income at all. In summary:
In this series, we’ve been looking at how ObamaCare, through its inherent system architecture, relentlessly creates first- and second-class citizens; how it treats people who should be treated equally unequally, for whimsical or arbitrary reasons. It’s all in the luck of the draw! If you live in the right place or have the right demographic, you go to Happyville. If you don’t, you go to Pain City.
All very much in contrast to simple, rugged, and proven single payer. (If I were writing the “Relentless Creation of Second-Class Citizens” today, having read Thomas Frank’s Listen, Liberal, I would stress that the complex eligibility determination system is also a make-work jobs program for the credentialed and aspirational classes — the 10% who are such a big component of the Democrat base — whose job consists in sending some to HappyVille, and some to Pain City. Randomly.)
- 6/3/2013: ObamaCare’s Relentless Creation of Second-Class Citizens
- 6/16/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (2)
- 7/1/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (3)
- 7/31/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (4)
- 8/5/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (5)
- 8/20/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (6)
- 6/16/2013: ObamaCare Icebergs: Burgeoning Medical Debt and the Wobbly Start-Up of the Federally-Run Exchanges
- 8/11/2013: Opposition to ObamaCare Considered Rational on Grounds of Equity
- 9/30/2013: Obama, ObamaCare, and Health Care as a Right
- 12/5/2013: Obamacare’s Drug Coverage Minefield
- 12/21/2013: Obama Exempts “If You Like It You Can Keep It” Cancelees from the Individual Mandate
- 1/1/2016: ObamaCare’s Present and Imminent Medicaid Woes
It’s unfair (but fun) to oversimplify neo-liberalism. However, for our purposes, all that is necessary is to be able to spot a neoliberal in conversation, or when writing an Op-Ed. This is easy to do: If they have a quasi-religious faith in market-based solutions, such that “Because markets” is axiomatic for them, and requires no further justification, they’re a neoliberal. Unfortunately for us all, the dominance of neoliberalism in the political class is nearly complete. TINA: “There is No Alternative” to the market. ObamaCare, with its insistence on a health insurance “marketplace,” is neoliberal to the core. Naturally, the successful defense of neoliberalism requires various doublethinking techniques, prominent among them the giving single payer advocates no “seat at the table” in policy discussions, and erasure of single payer programs, advocacy, and advocates from history. And even geography:
To put this another way, since the mid-70s, when Canada adopted its single payer system, we’ve conducted the largest controlled experiment in the history of the world. We’ve had two political systems spanning the same continent, both nations of immigrants and once part of the British empire, both mainly English-speaking but multicultural, both with Federal systems, and both with a free market system backed by social insurance. And the results of the experiment? The “evidence”? Canadian-style single payer wins hands-down.
Another way of saying this is that the battle for single payer is a battle against neoliberalism, the ruling ideology of our elites. Single payer is an important wedge issue.
- 11/22/2013: ObamaCare, TINA, Medical Ethics, and the Health Care Economist
- 11/27/2013: Krugman, on ObamaCare, Gets the Wrong Worm
- 3/28/2014: Hillary Clinton, Pre-2016, Gingerly Addresses ObamaCare Debacle, Supports “Evidence-Based” Changes
- 1/25/2015: The Destructive Effect of Getting a Permission Slip from the CBO in the Politics of Health Care
- 10/19/2015: ObamaCare’s Neoliberal Marketplace: Failing. And Fraud-Enabling?
- 11/1/2015: Ode to TINA: The New York Times Covers ObamaCare as Enrollment Opens
- 4/18/2016: ObamaCare’s Neoliberal Intellectual Foundations Continue to Crumble
- 5/18/2016: Market Fundamentalism on ObamaCare at the New York Times
- 8/8/2016: JAMA Turns Over Its Pages to Neoliberal Policy Erasure on Health Care, Because Obama
6. ObamaCare vs. Single Payer
The opportunity cost of ObamaCare is single payer; in fact, ObamaCare (once RomneyCare) was designed to head off single payer. I recall that readers liked this paragraph, so I’ll call it out:
The key point to remember in all discussions of ObamaCare is that neither it, nor indeed the entire private health insurance “industry,” should exist. They are rent-seeking parasites, economic tapeworms. One does not improve a tapeworm; one removes it.
To understand this simple point, all we need to do is look north to Canada, where we see a single payer system — they call it “Medicare” — delivering equal or better health outcomes at dramatically lower cost, without a health insurance industry, and without ObamaCare’s bizarre, mystifying, and above all unfair Rube Goldberg-esque complexity. In fact, if we’d passed HR 676 in 2009, we would have saved hundreds of billions of dollars by now (more than enough to cover everyone) and thousands of lives, though ObamaCare apologists don’t like to talk much about the excess deaths that ObamaCare’s achingly slow rollout caused and is still causing.
And with a special shout-out to Jonathan Gruber:
- 12/10/2013: ObamaCare and Its Opportunity Costs
- 11/17/2014: Jonathan Gruber, ObamaCare, and “Stupid Voters”: It Couldn’t Happen to a Nicer Shill
- 11/18/2015: Clinton, Finally Forced to Confront a Single Payer Advocate in Debate, Can’t Win on Policy, Falls Back on Demagoguery and Distortion
7. ObamaCare and the So-Called “Public Option”
The so-called “public option” is a tactic within the larger strategy of using a market-based, neo-liberal solution to head off single payer. Sadly, the “progressive” faction of the political class played a significant role in doing just that.
- 10/6/2010: Public Option Duplicity Revisited: Yet More Evidence of Obama Spinelessness
- 5/23/2016 Destroying Medicare to Save ObamaCare: Hillary Clinton’s “Public Option” Plan
- 8/29/2016: The Underground History of the So-Called Public Option (Plus Underpants Gnomes)
8. ObamaCare’s Death Spiral
An early call on the ObamaCare death spiral (too many sick people in the pool making claims for the revenues from well people not making claims to make up the difference and make a profit, leading to insurers further crapifying the policies to recover lost profits, leading more well people to leave the pool because of the crapification; rinse and repeat).
- 10/28/2015: Will Adverse Selection Force ObamaCare into a Death Spiral?
- 2/23/2016: ObamaCare Open Enrollment Whimpers to a Close, as Exchanges Continue Their Slow Death Spiral
- 8/17/2016: ObamaCare Death Spiral Accelerates as Aetna Pulls out of the Exchanges
9. ObamaCare Enrollment (and Gaming the Numbers)
ObamaCare enrollment numbers have always been soft; remarkably, data collection has been privatized. The Obama adminstration also regards metrics as exercises in public relations, and consistently games them. It’s also odd, or not, that the administration and the press use this metric at all, since measuring program success by enrollment confuses health insurance (enrollment) with health care (the actual delivery of services). There are also many issues with the enrollment process itself, with its complex eligibility requirements.
- 5/12/2013: ObamaCare Rollout: Feds to Use “Consumer Reporting Agencies” to Determine Eligibility Despite Penalty for Perjury
- 8/15/2013: ObamaCare Rollout: Kaiser Explains to Poor People in Non-Medicaid Expansion States How to Game the System by Lying
- 11/11/2013: Healthcare.gov Enrollments to Date a Pathetic < 50,000
- 12/19/2013: As Many Uninsured Oppose Obamacare as Favor It
- 2/14/2014: 20% of Obamacare Enrollees Failed to Make First Payment
- 3/2/2014: How Solid are the ObamaCare Enrollment Numbers? (With an Addendum)
- 1/12/2015: Why Enrollment Figures Are a Deceptive Metric for ObamaCare’s Success
10. ObamaCare and Public Relations
The Obama administration, as Yves often says, believes that there is no problem that public relations cannot solve. ObamaCare provides many proofs of this claim.
- 7/11/2013: ObamaCare Train Wreck on the Twitter: Administration PR Team Launches Google Hangout to Online Derision, Part I
- 7/12/2013: ObamaCare Train Wreck on the Twitter: Administration PR Team Launches Google Hangout to Online Derision, Part II
- 11/14/2013: ObamaCare Rollout: Administration PR Tactics and the First Release of Enrollment Numbers
- 5/16/2014: Yet Another Shoddy Democratic Hack Job from Paul Krugman on ObamaCare
11. ObamaCare Crapification (General)
ObamaCare’s system architecture, with its complex eligibility determination system and its requirement to leave private health insurance in place, creates an enormous amount of complexity for users. Sometimes, this only means a bad user experience. At other times, as with “balance billing,” ObamaCare can create the very medical bankruptcy problems that it claimed to have solved.
- 11/19/2013: Another Lurking Obamacare Problem: Balance Billing
- 11/20/2013: Michael Olenick: Obamacare Pits the 50% Against the 49%
- 12/9/2013: Michael Olenick: Consumer Reports Joins Obama in Telling Obamacare Big Lies
- 11/16/2014: The Crapified Magic of the ObamaCare Marketplace
- 1/11/2015: ObamaCare “Shared Responsibility Payments” Come Due on April 15, and It Won’t Be Pretty
- 10/4/2015: ObamaCare to Crapify Health Insurance at 26% of Employers with “Cadillac Tax”
- 3/8/2016: ObamaCare and the Crapification of Health Care: A Case Study, and a Growing Collection of Horror Stories
Yves frames many useless, but rental extraction-enabling, mechanisms as a tax on time. For example, you can take a day to figure out which policy you should purchase, and you can be additional hours on the phone straightening out the policy with the insurer, and many hours straightening out any billing errors. So who do you invoice for all those hours you spent, that you would rather have spent doing some more pleasant task, like getting your teeth pulled, or cleaning your refrigerator? Nobody. That’s why it’s a tax on your time, levied on you by neoliberals because markets.
- 1/22/2014: Michael Olenick: “Conversation with the Receptionists” – An Obamacare Skit
- 8/15/2014: Getting Sucked into ObamaCare is a Lot Like Being on Probation
Finally, the posts I can’t fit into any other category. The first makes an important point:
All in all that 31 million [projected enrollments] may well turn into 17 million [enrollments] or so before all this is done. And then we would have taken 9 years of passage, waiting, and implementation and would still have as many as 40 million people uncovered in 2017, and 40,000 annual fatalities.
That is the measure of the possible failure of the ACA.
Is that better than nothing? Sure…
Now, in retrospect, ObamaCare did better than that. Nevertheless, ObamaCare’s performance fell far short of projection, millions are still not enrolled, and excess deaths are clearly the result. It couldn’t be more clear that ObamaCare’s implementers — as good neoliberals — valued “the market” over human lives. As I’ve asked so many times: How can they live with themselves?
- 9/29/2013: ObamaCare’s Shameful and Lethal Three-Year History — and Future
- 12/13/2013: Why Obamacare Cannot “Insure” for Pre-Existing Conditions
- 3/14/2014: Obama Peddles Big Lie to Youth Demographic of “Between Two Ferns” — That ObamaCare Coverage Costs Less Than a Cellphone Bill
- 6/13/2014: ObamaCare Roundup: Constitutional Challenges, Profits, Medicaid, and Costs
- 7/29/2014: ObamaCare Roundup: Counting, Court Cases, Corruption, Narrow Networks, and an Amazing Catch on the Filibuster
- 9/4/2014: ObamaCare Roundup: Fun with the IRS, the Auto-Renewal Trap, and Continued Relentless Creation of Second-Class Citizens
- 11/3/2014: The Upshot’s ObamaCare “Interactive” Explainer in the New York Times: A Critique
- 6/1/2015: ObamaCare’s Problems Continue to Fester: Cost, Complexity, Quality, Coverage, Corruption in Covered Calfornia
- 11/2/2015: ObamaCare Open Enrollment Begins: Fraud-Enabling Front End, Collapsing Co-Ops, Constitutional Challenge
Readers, I hope this compendium is useful. I’m sure I’ve missed things, and may even have missed posts, or important issues. Please correct in comments, and I’ll update.