The History of ObamaCare, 2013-2016

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:

  1. ObamaCare and “Estate Recovery”
  2. The ObamaCare Website Launch Debacle
  3. ObamaCare’s Narrow Networks, and Health Insurer Gaming
  4. ObamaCare’s Lack of Universality
  5. ObamaCare’s Neoliberal Foundations
  6. ObamaCare vs. Single Payer
  7. ObamaCare and the So-Called “Public Option”
  8. ObamaCare’s Death Spiral
  9. ObamaCare Enrollment (and Gaming the Numbers)
  10. ObamaCare and Public Relations
  11. ObamaCare Crapification (General)
  12. ObamaCare as a Tax on Time
  13. Miscellaneous

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.

1. ObamaCare and “Estate Recovery”

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.)

  1. 2/11/2014: How Obamacare Raids the Assets of Low-Income Older Americans
  2. 2/17/2014: Consumer Reports Shills for ObamaCare, Pooh-Poohs Medicaid Clawbacks on Bizarre Assumption They’ll be Waived

2. The ObamaCare Website Launch Debacle

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.)

  1. 5/7/2013: Obama’s April 30 Presser on the ObamaCare “Train Wreck” (color-coded transcript)
  2. 7/8/2013: ObamaCare Rollout: Punts on Income Verification and Employer Insurance Checks, Setting Stage for Insurers to Call Mistakes “Fraud” and Rescind Policies
  3. 7/17/2013: ObamaCare Rollout: Will the All the State Exchanges Launch on Time? A Secretive Project Out of Control
  4. 8/25/2013: ObamaCare Staggers Toward the October 1 Finish Line
  5. 8/30/2013: ObamaCare Staggers Toward the October 1 Finish Line (2)
  6. 9/8/2013: ObamaCare Staggers Toward the October 1 Finish Line (3)
  7. 9/9/2013: ObamaCare Staggers Toward the October 1 Finish Line (4)
  8. 9/16/2013: ObamaCare Staggers Toward the October 1 Finish Line (5)
  9. 9/26/2013: ObamaCare Staggers Toward the October 1 Finish Line (6)
  10. 10/7/2013: ObamaCare Launch: First Hints of Real Back-End Problems on the Federal Exchange Begin to Appear
  11. 10/18/2013: Obamacare Rollout: Will Insurers Be Hoist on the Enrollment Petard?
  12. 11/30/2013: Michael Olenick: How My Experience with Shows “Better” Software May Not Be the Solution
  13. 10/23/2013: Obama’s Remarks on the ACA Rollout Debacle: From Selling Hope and Change to Hawking Insurance (color-coded transcript)
  14. 11/11/2013: The ObamaCare Rollout, Organizational Dysfunction, and Public Relations in the Administration
  15. 12/2/2013: Obama Kept His Head in the Sand During Fiasco
  16. 12/23/2013: America’s Shopper-in-Chief Has His Staff Sign Him Up for ObamaCare (But Not His Family)
  17. 8/7/2014: ObamaCare and Executive Impunity
  18. 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.

  1. 10/12/2013: Obamacare Narrow Networks: How They Affect Doctor Specialties
  2. 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
  3. 2/29/2014: ObamaCare: “Per Beneficiary” Limits a Loophole Insurance Companies Can Drive a Truck Through?
  4. 10/2/2015: ObamaCare’s Narrow Networks, and Who To Blame When “There Is No Alternative”
  5. 3/25/2014: ObamaCare Discriminates Against Poor People with Cancer (and Obama’s Lying Again)
  6. 5/1/2014: ObamaCare Clusterfuck: “Medical Homelessness” in California

4. ObamaCare’s Lack of Universality

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.)

  1. 6/3/2013: ObamaCare’s Relentless Creation of Second-Class Citizens
  2. 6/16/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (2)
  3. 7/1/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (3)
  4. 7/31/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (4)
  5. 8/5/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (5)
  6. 8/20/2013: ObamaCare’s Relentless Creation of Second-Class Citizens (6)
  7. 6/16/2013: ObamaCare Icebergs: Burgeoning Medical Debt and the Wobbly Start-Up of the Federally-Run Exchanges
  8. 8/11/2013: Opposition to ObamaCare Considered Rational on Grounds of Equity
  9. 9/30/2013: Obama, ObamaCare, and Health Care as a Right
  10. 12/5/2013: Obamacare’s Drug Coverage Minefield
  11. 12/21/2013: Obama Exempts “If You Like It You Can Keep It” Cancelees from the Individual Mandate
  12. 1/1/2016: ObamaCare’s Present and Imminent Medicaid Woes

5. ObamaCare’s Neoliberal Foundations

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.

  1. 11/22/2013: ObamaCare, TINA, Medical Ethics, and the Health Care Economist
  2. 11/27/2013: Krugman, on ObamaCare, Gets the Wrong Worm
  3. 3/28/2014: Hillary Clinton, Pre-2016, Gingerly Addresses ObamaCare Debacle, Supports “Evidence-Based” Changes
  4. 1/25/2015: The Destructive Effect of Getting a Permission Slip from the CBO in the Politics of Health Care
  5. 10/19/2015: ObamaCare’s Neoliberal Marketplace: Failing. And Fraud-Enabling?
  6. 11/1/2015: Ode to TINA: The New York Times Covers ObamaCare as Enrollment Opens
  7. 4/18/2016: ObamaCare’s Neoliberal Intellectual Foundations Continue to Crumble
  8. 5/18/2016: Market Fundamentalism on ObamaCare at the New York Times
  9. 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:

  1. 12/10/2013: ObamaCare and Its Opportunity Costs
  2. 11/17/2014: Jonathan Gruber, ObamaCare, and “Stupid Voters”: It Couldn’t Happen to a Nicer Shill
  3. 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.

  1. 10/6/2010: Public Option Duplicity Revisited: Yet More Evidence of Obama Spinelessness
  2. 5/23/2016 Destroying Medicare to Save ObamaCare: Hillary Clinton’s “Public Option” Plan
  3. 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).

  1. 10/28/2015: Will Adverse Selection Force ObamaCare into a Death Spiral?
  2. 2/23/2016: ObamaCare Open Enrollment Whimpers to a Close, as Exchanges Continue Their Slow Death Spiral
  3. 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.

  1. 5/12/2013: ObamaCare Rollout: Feds to Use “Consumer Reporting Agencies” to Determine Eligibility Despite Penalty for Perjury
  2. 5/21/2013: ObamaCare Rollout: How Not to Attract “The Young Invincibles”
  3. 8/15/2013: ObamaCare Rollout: Kaiser Explains to Poor People in Non-Medicaid Expansion States How to Game the System by Lying
  4. 11/11/2013: Enrollments to Date a Pathetic < 50,000
  5. 12/19/2013: As Many Uninsured Oppose Obamacare as Favor It
  6. 2/14/2014: 20% of Obamacare Enrollees Failed to Make First Payment
  7. 3/2/2014: How Solid are the ObamaCare Enrollment Numbers? (With an Addendum)
  8. 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.

  1. 7/11/2013: ObamaCare Train Wreck on the Twitter: Administration PR Team Launches Google Hangout to Online Derision, Part I
  2. 7/12/2013: ObamaCare Train Wreck on the Twitter: Administration PR Team Launches Google Hangout to Online Derision, Part II
  3. 11/14/2013: ObamaCare Rollout: Administration PR Tactics and the First Release of Enrollment Numbers
  4. 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.

  1. 11/19/2013: Another Lurking Obamacare Problem: Balance Billing
  2. 11/20/2013: Michael Olenick: Obamacare Pits the 50% Against the 49%
  3. 12/9/2013: Michael Olenick: Consumer Reports Joins Obama in Telling Obamacare Big Lies
  4. 11/16/2014: The Crapified Magic of the ObamaCare Marketplace
  5. 1/11/2015: ObamaCare “Shared Responsibility Payments” Come Due on April 15, and It Won’t Be Pretty
  6. 10/4/2015: ObamaCare to Crapify Health Insurance at 26% of Employers with “Cadillac Tax”
  7. 3/8/2016: ObamaCare and the Crapification of Health Care: A Case Study, and a Growing Collection of Horror Stories

12. ObamaCare as a Tax on Time

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. 1/22/2014: Michael Olenick: “Conversation with the Receptionists” – An Obamacare Skit
  2. 8/15/2014: Getting Sucked into ObamaCare is a Lot Like Being on Probation

13. Miscellaneous

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?

  1. 9/29/2013: ObamaCare’s Shameful and Lethal Three-Year History — and Future
  2. 12/13/2013: Why Obamacare Cannot “Insure” for Pre-Existing Conditions
  3. 3/14/2014: Obama Peddles Big Lie to Youth Demographic of “Between Two Ferns” — That ObamaCare Coverage Costs Less Than a Cellphone Bill
  4. 6/13/2014: ObamaCare Roundup: Constitutional Challenges, Profits, Medicaid, and Costs
  5. 7/29/2014: ObamaCare Roundup: Counting, Court Cases, Corruption, Narrow Networks, and an Amazing Catch on the Filibuster
  6. 9/4/2014: ObamaCare Roundup: Fun with the IRS, the Auto-Renewal Trap, and Continued Relentless Creation of Second-Class Citizens
  7. 11/3/2014: The Upshot’s ObamaCare “Interactive” Explainer in the New York Times: A Critique
  8. 6/1/2015: ObamaCare’s Problems Continue to Fester: Cost, Complexity, Quality, Coverage, Corruption in Covered Calfornia
  9. 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.

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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. Jim Haygood

    Wow … it’s like reading the Pentagon Papers all over again: careful, copious documentation of a premeditated disaster unfolding.

    Why not clickbait the headline —

    Obamacare: Secret History of a Trainwreck, 2013-2016 (you’ll be shocked!)

    1. Clive

      Oh, now you’re going to get me started!

      “London mum makes £1000 a week with just her laptop and”

      “10 ACA insurers which are much older and crappier than they look”

      “Baltimore Left Stunned by This Affordable Laser Eye Surgery”

      1. Jim Haygood

        “7 Celebrities Get Facelifts Paid by Obamacare”

        “Revealed: Obamacare Service Code for Breast Augmentation”

        “Frustrated Doc Fries Himself in the MRI Machine”

  2. fresno dan

    thank you so much for this!
    Distressingly, I think this shows the truth – even though people knew what would happen, why it would fail, the system is in the paws of those few who do well when the many pay more for less.

    1. Arizona Slim

      Me? I’m reminded of that Mission of Burma hit from 1981, “That’s When I Reach for My Revolver.”

  3. Ranger Rick

    I remember when the ACA passed. I got a letter in the mail from my employer informing me that my zero-deductible health insurance was no longer valid, that they were switching over to a self-insured plan “administered” by the same health insurer, and that I now had a deductible.

    I was less than pleased.

    1. tongorad

      My employer switched providers last year. This year we had to visit a doc for something minor. Pay up front, of course, for the doc visit since we have a massive deductible.
      Fast forward and I just received a bill from the previous insurer.
      Double, fraudulent billing!
      I predict a massive time-tax liability getting this straightened out.
      Those wacky insurance companies, aw shucks.

    2. Teejay

      I’m left wondering, was your zero deductible policy the type that disappeared in the fine print when you actually needed it and that’s why you had to change to one requiring a deductible. You had a great policy until you used it.

  4. OpenThePodBayDoorsHAL

    History of ObamaCare:
    Step 1. Obama takes single payer off the table, insurance billionaires rejoice
    Step 2. Adverse selection
    Step 3. Insurance premium hikes become biggest remaining positive contributor to US GDP

    1. Synoia

      Step 3. Insurance premium hikes become biggest remaining positive contributor to US GDP

      Err no. It’s a zero sum game.

      “Consumer Spending drops”

  5. allan

    A stupendous output. Lambert standing athwart history yelling ‘Stop!’

    A couple of anecdotes:

    Four people in my immediate or close extended family have been on ACA policies in the last few years.
    All of them had an insurer blow-up before the end of a year (Health Republic in NY, Land of Lincoln in IL,
    something in WA), forcing them to quickly shop and re-up for one or two months,
    start from scratch on deductibles and out of pocket maximums, and throw existing providers out of network.

    In one case, with the shutting down of the insurer impending but not yet in effect, my relative contacted an
    urgent care facility that was in-network, and the facility refused to take the allegedly still valid insurance.
    Presumably because they didn’t want to get stiffed by the bankrupt insurer, which happened
    to the tune of $200 million with Health Republic in NY.
    It was done over the phone, so no paper trail.

  6. clarky90

    New Zealand has a great public health system that is being eroded by big pharma.,-say-patients

    These are unproven treatments that cost hundreds of thousands of dollars- billed to a free socialized health system. Eventually (and quickly), the free health system (free delivery of babies, free health care for kids etc) will be bankrupt, and no more.

    A few people notice that I am Pro-Donald Trump. TPP (NZ is a member) will open the gates for the entry of EPIPEN, “USA-style” healthcare into NZ. Talk about Barbarians at the Gates. Donald Trump has pledged to stop TPP, and thus save our NZ health system. I love The Trump, for the sake of my kids and grandkids.

    Look at the wonderful healthcare we have in NZ, and weep for the USA

    1. tongorad

      I wouldn’t count on Trump or anyone else stopping TPP.
      Neoliberals have a way of getting their way. Always.

      Until they don’t. I hope to see a neoliberal policy rejected and terminated in my lifetime. But I have to wonder if neoliberalism is a stage 4 terminal cancer.
      I hope for your sake you NZ never encounters a neoliberal politician as lethal and vicious as Obama.

    2. Divadab

      I agree with everything you say except – that flim-flamming huckster Trump has you fooled it’s just his patter for the rubes
      He likes the current system just fine so long as it lines his pockets and keeps his line of Slavic princesses in plastic surgery and trinkets

      1. clarky90

        I trust him. The frikkking hysterics of the 1% and their camp followers (the retinue) give me great hope.

          1. clarky90

            Believe me, vulgar has never bothered the 1%. The conniving destruction of the Middle East is vulgar. Are you being sarcastic?

  7. mirjonray

    Re: Obamacare and Estate Recovery. Oh, yes, that’s a real problem. The only reason why people aren’t shouting from the rooftops about this is because a lot of people like us who are income poor and (relatively) asset rich are often too embarrassed to admit that we have such low levels of income.

    Blue Cross Blue Shield in my home state of Michigan has supposedly fallen victim to that national curse of too many sick old people and not enough healthy young ones enrolling in their plans. That puzzled me because BCBS has always been the major player in Michigan, and is practically the only game in town. BCBS has ALWAYS insured a lot of sick people, and never had enough healthy ones. Where were all of these sick people coming from who presumably didn’t previously have health insurance? One person told me they were coming off of Medicaid plans, but that didn’t make sense to me. Why would you drop Medicaid and pay a fortune for a plan for which you were ineligible for subsidies because you didn’t have enough income? (Maybe because you hit age 55?)

    Part of my answer about rising costs came from this article in the Detroit Free Press.

    Almost hidden in the article was this:

    “Blue Cross says it has been losing about 20% of its annual customers in the months following the conclusion of each open enrollment period. This was unexpected. ‘They just get the services and then drop coverage and end up paying a partial penalty at the end of the year,’ said Rick Notter, Blue Cross’ director of individual business.

    The full ACA penalty this year for skipping insurance is $695 for an adult or 2.5% of household income, whichever is greater.”

    1. nycTerrierist

      Considering the non-rich never participated in the so-called ‘recovery’,
      the penalty for skipping the ACA is all the more unconscionable.

      Obama’s ‘legacy’ indeed.

    2. Jack

      We dropped coverage the end of August. It was just costing way too much. A plan we had the year before the ACA started we were paying $250 a month, for much better coverage and a deductible of $2500 (BCBS). This year the premium is almost $800 (again BCBS), with a $6500 deductible. Next year will be 25% more, at least. And in SC there will only be one insurer, again BCBS. Another factor in dropping it is we are moving to the NE where rates are half what they are in the South, with better coverage.

  8. dbk

    First: congratulations, Lambert, this is absolutely excellent in every respect – I’ll bookmark the link as a reference in future.

    Second: Why is it that while “Medicare” is recognized as the most successful health care delivery program the U.S. has ever implemented, “Medicare for All” calls forth such animus? Those over 65 deserve single-payer, and those under 65 don’t? What’s the logical justification for this?

    Third: Why does the PNHP get so little traction in the MSM? Physicians are experts on the health care delivery system, why are “policy experts” (sic) listened to, and physicians ignored?

    Fourth: Given that single-payer is the most effective (and cost-effective) system for providing cradle (and pre-cradle) to grave health care, what arguments can be logically mounted against it?

    1. ambrit

      Young people. Older people, unless they are rolling in dough, cannot emigrate due to common net worth oriented immigration rules in many countries.

      1. Lambert Strether Post author

        Southeast Asian countries tend to have requirements of $25K in the bank and/or a pension. For many, that’s a stretch. If you can sell the house, it might not be such a stretch.

        1. Felix_47

          Unless you are a third world person from the India-Turkey-Africa population explosion crescent you don`t have a chance in Germany to even stay unless you have a fixed documented income and health insurance. And if you get an Aufenhalterlaubnis with the above forget about a job permit. Even though essentially all of the asylum seekers are seeking a better economic future….(asylum from drought, overpopulation and unemployment) might be a more accurate term an unemployed worker in the US would have no hope of escape from the same factors and I suppose that would be the case throughout Europe. We are resettling Afghanistan to a degree since Bagram has been declared a permanent base.

  9. Oregoncharles

    “including (and a good thing, too) the requirement to cover people with pre-existing conditions.”
    Morally, it’s a good thing; but it’s also the reason for the Mandate and the death spiral, because it makes a nonsense of the very concept of insurance.

    In car-insurance terms, it means you can buy insurance for an accident that ALREADY HAPPENED. Yes, it may get people badly needed health care (or not, given the crapification), but it makes the whole concept unmanageable. As the companies probably told them, behind the scenes. But that didn’t prevent them from gobbling down all those subsidies.

    Single payer avoids this because it isn’t really insurance, in the usual sense; it’s a transfer payment, like Social Security. Current taxes are used to pay for current needs. (Or current money creation, whatever.)

  10. Robert NYC

    NC deserves immense credit for its coverage of the Obamacare debacle. As someone who was in the individual insurance market since 2009, I can tell you that the ACA completely destroyed the insurance market from my perspective. Our premiums have tripled, networks are smaller and more complicated, coverage is worse and it’s gotten so convoluted that it’s nearly impossible to shop for plans. I am still in a state of disbelief.

    In any case NC has covered the reality of what happened unlike the NYT which has been a mindless shill for Obamacare.

  11. Jay M

    Obama care,
    it’s like they didn’t care
    payday loans and and houses rare
    jobs surfeit, at the bottom
    the well trained hold the horses

  12. djrichard

    So looking ahead, let’s pretend the Fed Gov rolls out a “mouse version” of the public option (like Kip Sullivan describes it at: and which Lambert linked to in his August 29th write up).

    It wouldn’t be all that different than dropping a public utility on a landscape that is already populated with private utilities. At best, the public utility will offer the same price points as the private utilities already out there (because being mouse-sized it won’t have economies of scale). At worse, the public utility will be ghettoized and left with the poor and sick and therefore have a higher cost structure which it would be forced to pass onto its subscriber base (who would presumably do as they always do: remain uninsured).

    Unless of course, the public utility gets some kind of subsidy. And I could easily see that happening. Rural telcos get this type of subsidy in the form of universal service fund, which is basically a tax on non-rural telcos, i.e. ones which serve “healthier” markets. See

    If the powers-that-be are looking for a path-of-least resistance (and they are), I could easily see them backing themselves into a subsidized “mouse-sized” public option. And who says the subsidy has to be funded by other players in the private space. It could easily be a funded by the Fed Gov itself. That’s what Fed Govs do when they don’t want to be creative otherwise.

  13. marco

    I know this blog doesn’t do “assignments” but it would be great to find personal ACA horror stories all in one place. My experience with Aetna from 2014. I purchased a platinum $0 deductible for $575 a month in Illinois. Then AFTER I started using the insurance they retroactively increased my deductible to $1000. They said there was a “hiccup” on the exchange web site and I did NOT purchase a $0 deductible plan. Obamacare is like having CAR insurance and not being able to afford to DRIVE. Sure you can sit inside…maybe honk the horn or roll down the window but what’s the point if you can’t DRIVE the damn car. So when I hear Klein or Krugman or Gruber or some Dem Pol singing the glories of how many MORE people are insured I cannot help wretch at the clever game of semantics going on. Having health insurance does equal access to health care.

  14. JEHR

    Canadian single-payer health care is being weakened by privatization: We already have user fees for blood tests, for instance.

    I feel we will have a constant battle on our hands from now on to keep our single-payer system and to keep out those who would privatize (and make profits from) our healthcare.

    Any sovereign country with its own currency can afford to give each citizen decent health care. Where will all those health insurance companies make profits if single payer comes to the US? It’s a scenario that boggles the mind!

  15. Cry Shop


    The Florida Office of Insurance Regulation announced today that premiums for Florida individual major medical plans in compliance with the federal Patient Protection & Affordable Care Act (PPACA) will increase an average of 19% beginning January 1, 2017. Per federal guidelines, a total of 15 health insurance companies submitted rate filings for the Office’s review in May. These rate filings consisted of individual major medical plans to be sold both on and off the Exchange. Following the Office’s rate filing review, the approved rate changes on the Exchange range from a low of -6% to a high of 65%. This information can be located in the attached “Individual PPACA Market Monthly Premiums for Plan Year 2017” document.

    These rate increases also don’t reflect the reductions in coverage, the increase in co-pays, etc.

    “Congress may not simply “commandee[r] the legislative processes of the States by directly compelling them to enact and enforce a federal regulatory program. …. We have always understood that even where Congress has the authority under the Constitution to pass laws requiring or prohibiting certain acts, it lacks the power directly to compel the States to require or prohibit those acts.”

    If Congress wants to regulate the business of insurance, it can do so. If Congress wants to establish a national risk adjustment program for insurers participating in the ACA, it can probably do so. If Congress wants to condition various subsidies such as advance premium tax credits on states running effective Risk Adjustment programs, it can probably do so. What it can not do, however, is to simply order the states to perform risk adjustment, particularly on terms dictated by the federal government.

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