TrumpCare: ObamaCare, Medicaid, Medicare, and the Veterans Administration

By Lambert Strether of Corrente.

Assuming that Trump takes office on January 20, we can expect health care policy to shift from the left side of the Overton Window to the right, even as the only solutions that remain “on the table” are neoliberal and markets-first non-solutions. Let’s begin by setting the baseline for a rational and humane health care policy — i.e., not neoliberalism — as a universal benefit.[1] From Richard D. Lamm and Vince Markovchic in the Denver Post:

U.S. is on fast track to health care train wreck

In 2015 we spent $3.2 trillion on health care, which was $10,000 per person in the U.S., ($25,000 for a typical American family). This is 17.5 percent of the U.S. Gross Domestic Product (GDP). To put this in perspective, this is more than twice what most other developed nations spend on health care while insuring all of their residents. This year we are on track to exceed that amount with it being 18 percent of GDP.

Even with the implementation of the Affordable Care Act, we still have 28 million people with no health insurance, and many more are under-insured due to rising co-pays and deductibles….

Of the $3.2 trillion health spending, 70 percent goes directly to fund the cost of our healthcare. The remaining 30 percent is spent on administration and profit, which is more than twice that of any other nation. In 2014, studies published by the Institute of Medicine, Rand Corporation, and the Center for Medicare/Medicaid Services estimated that out of total health care spending, as much as $900 billion, or about one third of our total spending, can be attributed to waste, fraud and abuse.

This current system is unsustainable, but who will tell the American public? We suggest that the solutions to the real problems of health care are hardly being talked or written about.

The ideal health insurance system is one that: provides free choice of hospitals and doctors; provides insurance coverage to all at all times (i.e., not tied to an employer); is affordable and will remove all risk of medical bankruptcy. This system should have an administrative cost of less than 5 percent and have everyone in the risk pool, thus making premiums affordable. We have such a system now: Medicare covers all persons over 65, those on total disability, and all renal dialysis patients.

Medicare, with all the fraud and other issues, still operates with about 3 percent to 4 percent overhead. That is much less than the profit and overhead added by U.S. health insurers, which is instead 15 percent to 20 percent. In addition, Obamacare, Veterans Affairs and Medicaid each add another entire layer of expensive bureaucracies. All these, along with the government being unable to bid for drugs purchased under Medicare, add up to unnecessary cost and waste in our system.

Similarly, there would be tremendous cost savings if under Medicare as a single payer, it is authorized to negotiate for hospital care on a more cost-efficient and more comparable basis across the nation.

So, the health insurance companies are parasites who should be removed. Now, I don’t know why Lamm and Markovchic don’t just lower the age for Medicare eligibility from 65 to zero, like Teddy Kennedy proposed. And I also don’t know why Democrats (including Sanders) aren’t prefacing every statement they make on heatlh care with “Of course, Americans deserve Medicare for All. Until then….” Instead, they’re digging in to defend a flawed system that hasn’t covered 28 million people, instead of going on the offense for the universal benefit. (That’s the difference between “resistance” and “revolution,” I guess. The one is reactionary; the other is, er, progressive.)

Anyhow, it is what it is and we are where we are. Absent a universal benefit[1], we get health care silos: ObamaCare, Medicare, Medicaid, and the Veterans Administration, among others. In this post, I’m going to take a very quick look at the current news in each silo. All the silos are in decay and disrepair — except from the standpoint of those who profit from them, of course — and all suffer from neoliberal infestations, but the forms of decay and the degrees of infestation differ. So the post will be a bit of a patchwork, but then the health care system itself if a patchwork. As always, I welcome comments from readers with informed experience interacting with these systems, for good or ill.

ObamaCare: Repeal and Replace, but How, When, and with What?

On ObamaCare repeal, Chuck Schumer suggests: “It’s a political nightmare for them. They’ll be like the dog that caught the bus.” Heaven forfend Schumer should defend a universal benefit, but on this he could be right. Throwing 30 million people off the rolls[2] is a heavy lift, even for Republicans. That’s because there’s really no popular consensus for doing it:

But the euphoria of finally acting on a long-sought goal will quickly give way to the reality that Republicans — and President-elect Donald Trump — have no agreement thus far on how to replace coverage for about 20 [or 30] million people who gained insurance under the health-care law.

Obamacare continues to be viewed unfavorably by Americans, but the politics of undoing the law are complicated. A Kaiser Family Foundation poll after the election showed 26 percent want to repeal it, while 17 percent want to scale it back. Nineteen percent want to move forward with implementation and 30 percent want to expand it.

It’s also not clear what would happen to Republican border states like Tennessee and Kentucky, that benefited signifacantly from Medicaid expansion under ObamaCare.

So the Republicans want Democrats to hold hands with them as they jump off the cliff. Let me know how that works out:

Some Republican aides say they may pursue a replacement through a series of small bills as opposed to one big measure. Leading Republicans such as Senate Majority Whip John Cornyn of Texas have said they want Democratic buy-in on a replacement plan. Breaking a filibuster would require the support of at least eight Democrats.

(Of course, reconciliation requires a bare majority, and the filibuster can be altered or abolished when the Senate adopts its rules at the start of a session.)

So the Republicans are toying with various ideas, some of which involve kicking the can down the road (“three year delay”), or even off the road entirely:

Now comes the American Enterprise Institute’s conservative health wonk James Capretta with an idea that cuts to the chase: Why not just “grandfather” all the people currently receiving benefits via the ACA and make whatever the new “replacement” system turns out to be prospective for new people seeking assistance?

It is also worth noting that Republicans have not had much luck in the past convincing people to accept radical policy changes by grandfathering those most immediately affected. George W. Bush’s proposed partial privatization of Social Security was supposedly only going to affect people aged 55 or younger. The same was true of Paul Ryan’s original Medicare voucher proposal.

(ObamaCare enrollment hit a record high this year, so I wonder if people were acting on rational expectations of a grandfathering solution. I know I thought of it.) So the 115th Congress should be interesting. However, if the 21st Century has taught us anything, it’s that it’s always possible to make a bad situation worse. Remember the ObamaCare rollout debacle? Does anybody believe the Republicans will do any better at a rollback?

Medicare: Balance Billing

Naked Capitalism covered ObamaCare’s balance billing problems back in 2013:

One of the proofs that Obamacare is really about helping insurers and Big Pharma rather than ordinary Americans is its failure to do much about the seamy practice known as balance billing.

Say you have a scheduled procedure, like getting a stent. Like most Americans who have health insurance, you are in an HMO or a PPO. Your doctor, who is in your network, schedules you for the operation at a hospital in your network. You assume the only thing you need to worry about is a fairly minor co-pay and recovery.

But weeks later, you find that the anesthesiologist wasn’t in your network, and you are hit with a $12,000 bill for his services. And this sort of scamming (hospitals knowingly putting people on a surgical team that they can bill at huge premiums to negotiated rates) is routine. And of course, if the ambulance takes you to an emergency room that is not in your network, the outcome can be catastrophic.

And now, the Trump administration is considering expanding this pleasant practice to Medicare:

“[B]alance billing” [is] why the American Medical Association is strongly supporting Donald Trump’s pick of [the aptronymic] Rep. Tom Price (R-Ga.) to lead the Department of Health and Human Services, which oversees Medicare. … In 2011, Price (an orthopedic surgeon himself) introduced a Medicare “reform” bill in Congress that, among other things, would have brought balance billing to the program. This

Balance billing is basically illegal for Medicare patients…

Permanently obliterating the financial security of helpless families with no or bad insurance as a loved one dies slowly and painfully of a chronic illness is a nice little profit center for providers. But it pales in comparison to the gravy train they might get if they can bring balance billing to Medicare. Seniors use far more care than the younger exchange population, and there are a lot more of them — 55.5 million, versus 12.7 million people on the exchanges. Perhaps most importantly, they’re quite a bit richer on average. Many seniors have been scrimping their whole lives to save for retirement, in keeping with decades of agitprop from conservatives and Wall Street, and the more sociopathic among the health-care population are licking their chops at the prospect of being able to devour those nest eggs.

(I like Ryan Cooper. The man can write.) So, like I said, it’s always possible to make things worse…

Medicaid: Privatization in Iowa

Let’s start out by noting that Medicaid has a serious neoliberal infestation problem:

More than two-thirds of states contract out some or all of their Medicaid program to private companies. The benefits of the practice and its impact on quality and cost of care have been unclear, however.

The Des Moines Register:

HHS believes 57% of Medicaid beneficiaries were enrolled in Medicaid managed-care organizations as of July 1, 2011, compared with 10% in 1991. The consulting firm Avalere Health projects that 75% of Medicaid beneficiaries will be covered by managed-care organizations starting in 2015. A recent U.S. Government Accountability Office report, using fiscal 2011 data, found Medicaid managed-care plans received about 27%, or $74.7 billion, of federal Medicaid expenditures.

The rush into Medicaid managed care came despite limited evidence that the plans save money for states and the federal government.

Iowa’s Republican governor Terry Branstad controversially privatized Iowa Medicaid services, on the (ostensible) premise that the state would save money (see Lamm and Markovchic, supra). Oops:

Iowa Medicaid payment shortages are ‘catastrophic,’ private managers tell state

In a Nov. 18 letter to Iowa Medicaid Director Mikki Stier, a UnitedHealthcare executive also warned of financial problems. Kimberly Foltz, chief executive officer of the company’s Iowa branch, wrote to Stier that she appreciated the state’s efforts to address some of the issues, “but overall the program remains drastically underfunded.”

Foltz wrote that experts from the Milliman firm, who were hired by the state, underestimated by 40 percent how much it would cost to cover the tens of thousands of poor Iowans who were allowed to sign up for Medicaid under the federal Affordable Care Act.


The mistake “suggests there were material flaws in the rating projection,” [Foltz] wrote.

Oops. (Had UnitedHealthcare no data to check Milliman’s figures?)

Foltz wrote that one way to help make up for the shortfall would be to allow the managed care companies to negotiate down how much they pay pharmacies to fill prescriptions. She suggested her company could cut those rates by nearly 90 percent. Hill said the contracts are written in a way that would make it difficult for the managed care companies to opt out unilaterally. But she said the companies could argue that the state and its actuarial firm, Milliman, did not properly estimate the costs of covering care for Iowa’s poor and disabled residents. “Conceivably, that could be a material breach of the contract,” which could allow the companies to bail out of the project, she said.

A nice Christmas gift for Terry Branstad. (The 90% figure seems to me remarkable.)

Of course, the real solution to cost problems is to abolish the insurance companies altogether, and use the power of single payer to beat back Big Pharma. But then you knew that.

Veterans Administration: Creeping Privatization

Finally, let’s take a look at the Veterans Administration. (I’m by no means an expert in the VA, and so readers will correct me, but my general impression is that the VA rations by queuing but can’t admit it, which has caused them political problems. But once you’re in, the care is good, which presumably explains why veterans themselves don’t want to “privatize” it. However, I think privatization as a frame is slightly deceptive, as we shall see (even if Sanders adopts that frame).

So, here’s Trump doing the Trump thing, which is — and do not underestimate him! — translating policy into vivid phrases voters can grasp immediately:

TRUMP: “We think we have to have kind of a public-private option, because some vets love the VA. Definitely an option on the table to have a system where potentially vets can choose either/or or all private.”

Brilliant of Trump to hijack the virulently memetic phrase “public option” — the bait and switch vaporware “progressives” used to suppress single payer advocacy in 2009 — with the conservative-sounding “public-private option.” And here Trump explains how such an option would work from the user’s perspective. Poltico:

Trump has insisted that what he wants is not to hand the veterans’ support mission entirely to the private sector. “No, it doesn’t have to be privatization,” he said in May. “What it has to be is when somebody is on line and they say it’s a seven-day wait, that person’s going to walk across the street to a private doctor, be taken care of, we’re gonna pay the bill.”

He has also proposed that all veterans be able to use their veterans’ IDs to get care at any hospital or doctor’s office that accepts Medicare.

Vets could use their ID cards! It’s brilliantly simple![3] It’s also a bridge too far for veterans:

But veterans’ groups see that as a major step toward privatization because it would allow veterans to opt out of the VA health care system. That is different from the recommendations of a recent federal Commission on Care, which pushed for the VA to oversee a network of qualified private health care providers to supplement VA-run hospitals and clinics.

But there’s less to this distinction than there seems to be at first sight. Trump proposes “walk[ing] across the street to a private doctor”; and the Federal Commission proposes “walk[ing] across the street to a certified private doctor.” Since the VA actually delivers health care, both solutions “allow veterans to opt out of the VA health care system,” and so both destroy the universality of the benefit. The Commission on Care (PDF) explains certification:

VHA credential community providers. To qualify for participation in community networks, providers must be fully credential ed with appropriate education, training, and experience, provide veteran access that meets VHA standards, demonstrate high-quality clinical and utilization outcomes, demonstrate military cultural competency, and have capability for interoperable data exchange.

Oh. Credentials. Not that I don’t want medical personnel to have them, but isn’t this rather a dog-whistle for liberals? And:

[A]ddressing veterans’ needs requires a new model of care: rather than remaining primarily a direct care provider, the VA should become an integrated payer and provider.

So, from being the American equivalent of the UK’s National Health Service, a “direct care provider” (even if the vile Tories are gutting it), the Commission proposes that the VA become more like Canadian Medicare for All, a single payer system. I told you it was a patchwork!

Now, let’s step back for a minute. The Commission was set up in 2014 under Veterans Access, Choice, and Accountability Act (VACAA), which was designed to solve a queueing crisis through “choice,” i.e., by allowing veterans who are unable to get an appointment in a reasonable time to seek care outside the VA. Now, a suspicious mind would put this under the heading of a neoliberal pattern for destroying a universal public benefit: 1) Underfund the service; 2) Wait for the inevitable problems; 3) Publicize them; 4) Push through a privatizing solution; 5) Rinse and repeat until the public service is destroyed. The VACAA was quite small. The Commission’s proposals are not so small. And in a decade or so, if the neoliberals get their way, the VA will be where Iowa is today, even if it does pass through a single payer phase on the way.

That’s why I think the privatization frame is a little deceptive. Yes, the ultimate goal, as with all neoliberal programs, is privatization. But it can take place a little at a time. For example, from Stars and Stripes:

Concerned Veterans for America, or CVA, is a veterans advocacy group in the Koch brothers’ political network and has been one of the most vocal critics of VA since the 2014 wait-time scandal.

The CVA is poised to become more influential under the new administration, as President-elect Donald Trump has tapped the group to help overhaul the veterans health-care system. The most controversial proposal by the group is an expansion of veterans’ health-care options in the private marketplace – which critics, including traditional veterans advocacy groups and Democratic lawmakers, say could lead to the dismantling of the current VA..

But CVA has not proposed a wholesale transfer of VA’s services over to the private sector – which is what “privatization” usually describes.

No, there is no “wholesale transfer.” Now. That’s for later, as with the Tories and the NHS.


So, what we have is a number of different battles on different fronts: ObamaCare, Medicaid, Medicare, and the Veterans Administration. It would be nice, and politically useful, if all these battles could be seen as a single theatre of war: Are we to have a humane and rational health care system — a universal benefit — or are we to have TrumpCare: An expensive and lethal mess?


[1] In of the earlier stories on Trump administration health care policy, the Times suggested that the Republicans seek a universal benefit. See FAIR, “Media Legitimizing GOP’s ‘Universal’ Health Plan That Doesn’t Exist.” I’ll believe it when I see it. The Democrats didn’t do it, so why would the Republicans?

[2] The 30 million figure comes from the Democrat nomenklatura at Think Progress, who helpfully calculate the number of deaths that will result. Ironically, they never calculate the lives saved with Medicare for All.

[3] Heaven forfend that any adult could use, say, their Social Security card for the same purpose.

Print Friendly, PDF & Email
This entry was posted in Health care, Politics on by .

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. Elliott Gorod

    Medicare is supposedly funded by taxes
    Unfortunately taxes go directly to the Treasury’s general fund which pays for general expenses
    If Medicare is ten percent of the budget, it receives only 10 cents in cash for every dollar allocated
    The rest is debt
    What insurer other than the government could function like this
    An entity which supposedly can access infinite dollars should not be able to save these magical dollars for future liabilities

  2. EndOfTheWorld

    The VA would cease to be such a huge issue if the US would cease fighting futile, idiotic—-dare I say, demonic—–wars thousands of miles from its borders, in desolate wastelands, which result in innumerable medical catastrophes. You have a lot of guys (and a few girls) who require multiple operations just to keep them from dying. They will need medical, and often psychiatric care, as well as a big disablility check, as long as they live. This is a direct result of the Bush/Cheney decision to stupidly invade. In Trump’s defense he called them out on this stupidity, won the election and terminated any pretensions the Bush family had to royalty. For that alone Trump should be praised.

    1. JTMcPhee

      But let us remember that for damaged-servicemen’s needs that the VA is supposed to provide for to even start to taper off, it will be a decade or more AFTER the last Troop “comes home” before the bulge even starts to trend downward. The costs of treatment and care tend to INCREASE for GIs post-service-connected injuries.

      And in case you are not aware, VA disability is just Workers Comp for Troops — the MAXIMUM amount paid by the “employer” (that’s you and me, according to the theory) for 100% total and permanent disability is about $3,000 a month, , and the Congress is so “generous” that if you have dependents, you might get $300 or $400 a month more.

      So I guess we disabled vets should be happy that at least we are getting more than the official poverty level in income, and if we survive to 62 we can “collect” our Social Security prepaid benefits too! and of course we get the best “health care” that the VA can offer (read that clause carefully, okay?) and some preferences for certain jobs, and gee whiz, a mortgage guarantee if we can afford the payment after un-covered expenses and all… What a deal, eh?

      Our Rulers used to be a little afraid (“The Third Rail of Politics,” to which someone has apparently turned off the juice) of old people with canes and walkers and votes. They’ve worked hard over decades, and with significant effect, to undermine the power of any of that. I wonder what happens if they continue to fork with GI benefits, such as they are — especially if, as is shown in at least a couple of anecdotes (NDAP, GIs at Occupy and Murder by Cop events) they can link their esprit to the other pieces of the polity that are being given the “Two Rules” treatment by the Fokkers at 12 o’clock high… So we don’t get “stupid”ed by them into kicking down.

      I have my father’s naval officers manual from WW II. In it, as in Army equivalents, there is advice on selecting a “sin eater” for the unit — some mope who everyone can feel superior to, dump on and abuse — and if the mope drops out of ranks (see, e.g., “Platoon” in the “latrine scene,”, you, the officer or NCO, anoints the next lowest mope to become the butttt…

  3. susan the other

    Silos indeed. Silos and the silage of medical identity politics. Thank you Lambert. I wish I could read this stuff without becoming almost paralyzed with rage. We the people need single payer. It is the only thing that will work. We need it now. The politicians do not offer single payer as an option because it is the one thing we know we want. They are protecting both the insurance companies and pharma. It is a disgrace. Insurance and pharma must serve us. We have no goddam obligation to serve them. But too bad for the entire system – insurance and pharma are profit based industries – gone senile. They do not know how to function rationally… “balance billing” for medicare victims? great. Just stop the rot whether it’s internal or external. Just do the right thing. Otherwise we the people must form a new industry which starts with the single payer premise and works up the structure of modern medicine for all – without the baggage of the medical profiteers. Hey, it’s a free country. They can go to hell.

    1. reslez

      It’s profit-taking from the sick and poor — the most evil behavior imaginable — and the imposition of fierce burdens on those at death’s door, fighting to survive. Our health care system/scam is inhumane, unethical, and serves only to line the pockets of the rich.

      We can’t all immigrate to Ecuador for health care. We have to build the nation we need where we are. In ancient Rome the Christian faith began to spread through the empire partly because of the charitable works of the Christians. They believed in and practiced radical poverty, charity to the poor, care of the sick. At church service they distributed food. As capitalism inflicts repeated wounds on the public body maybe we should look back to those practices for inspiration, perhaps not for religious reasons but in service of radical morality.

    2. Katharine

      Thanks, Lambert, indeed, and Susan the other! It’s information like this, and outraged commentary like this, that will shift the damn Overton window back where it belongs. (I hate references to it that seem to make it a disembodied thing like the invisible hand, with no connection to human machinations. It is where it is because certain people have pushed it there, not because that position conforms to actual public opinion.)

      1. Lambert Strether Post author

        > It is where it is because certain people have pushed it there

        True. An assumption so basic I didn’t feel the need to state it. The Overton Window is where it is because of contestation (or not).

  4. Crazy Horse

    The only really viable personal solution to the American Medical Extortion System is to immigrate to a civilized country. It is not going to be fixed by a president who believes that fact is whatever he might be tweeting at the moment and is so full of s—t that he requires 33 bathrooms in Mar-A-Largo, his winter White House. And it certainly wasn’t improved by Obumber’s efforts to reward his Masters and increase the profit level of the Medical Insurance Cartel.

    Pick almost any country— Cuba if you like short skirts and Spandex, Canada if you like civilized citizens and howling blizzards, or Colombia if you want a privatized health care system that ranks higher than the US and costs a fraction as much.

    1. Kokuanani

      I suggest you spend some time investigating the realities of being able to immigrate to a “friendlier” country. Short story: they don’t want us, and erect all sort of barriers to keep us out. Canada, Ireland, New Zealand — they all can see the American “health care [sic] refugees” and don’t want them taking advantage of their systems, particularly since those refugees haven’t paid into their system.

      1. Carla

        You are right. Those who are not war refugees have to buy their way into Canada–the older and potentially less useful you are, the more it costs. For someone 60 or over, it costs many hundreds of thousands of dollars. And I think this is appropriate. Clearly, we are incapable of creating a functioning democracy in our own country. Why should other nations welcome us to come in and crap up their societies? Americans bring crass materialism and guns. Who needs more of that?

        On the other hand, Crazy Horse, if you’re serious, I suggest checking out Ecuador.

      2. Yves Smith

        Agreed 100%. It is pretty much impossible to emigrate if you are over 30, maybe 35. And even then you have to be well educated. It’s a odd sign of American provincialism for it to be common not to understand that advanced economies are pretty hostile to people overstaying the typical 90 day tourist visa. Most countries will let in young people that they think will contribute (as in get a job, have kids, pay taxes). They assume everyone else wants to leech off their welfare state.

        The only ready ways for older people to get in is spousal or by being sponsored (as in someone hires you). But if you are sponsored, the sponsorship ends if you lose your job. And even then, the employer typically has to prove that they couldn’t find anyone local with the right skills and had to hire a furriner.

        And most countries are pretty tough on spousal visas too. For Australia, if memory serves me right, you have to have been married at least two years. And they put the couple through all sorts of questions…separately…to see if the answers match up. Like “What does you partner eat for breakfast? What color are the sheets? How long did you date before you were married? How many people attended your wedding? What car did you own right after you got married? How do you divide household chores?”

        1. Fiery Hunt

          Without seeming to endorse the Trumpster fire, doesn’t the reality of other nations’ immigration process suggest ours is way too lax? Living in California, I know several people of Mexican origin who totally game the health care/welfare system; one’s a dental assistant making $40,000 a year, another gets $35/hr for auto body work. It seems to me that immigration is an integral issue with health care costs.

          I myself, self-employed making $50,000 a year, have no insurance. Paying $470 a year in shared contribution taxes for the privilege..better than than the $10,000 (in monthly dues and deductibles…so far anyway.)

          1. dw

            well they came for the jobs, not the benefits. as Mexico has better benefits than we do. that they come for our benefits, is a conservative scam.

        2. RDE

          There is a huge gap between your perception and my reality. When I emigrated to Canada from the US I was 60 years old and had less than $2000 in assets. I immediately received full health care coverage, whereas in the US even Medicare often has co-pay requirements that are higher than the total cost of the procedure in Mexico or Colombia.

          In Canada I worked with all kinds of immigrants, from Chinese money launderers to Cambodian survivors of Pol Pot. In Vancouver immigrants likely are a majority, having arrived in waves ever since the Hungarians fled the failed revolt of 1956. Even among the recent arrivals from China, India and SE Asia, I guarantee that the million or so immigrants in Vancouver didn’t all buy their way in at a cost of hundreds of thousands of dollars.

          1. Yves Smith

            I have no idea how you got in. I DID emigrate to Australia and know the ropes there.

            I punched in your story into the Canadian immigration questionnaire and it very clearly says you would not be eligible. This was the only carveout:

            “Most provinces have special programs to help people move there. In most cases, you must already have a job offer, an investment plan or work experience in the specific province. The rules for application are different for each province.”

            So what exactly are you not telling us?

            This is consistent with what I said, that you had to have a sponsor. I suspect that is the part you are omitting. Most advanced economies are hostile to immigrants over 50.


          2. dw

            if you try to do that today, you will find it has changed a lot. seems like they tightened up the requirements a few years ago

      3. Benedict@Large

        In insurance, this practice is called “controlling the pool”. If an insurer (even a single-payer government) does not control its pool (of insureds, it will sooner or later become the target of people needing insurance but not having it available, and this will eventually break the payments system.

    2. Katharine

      You can’t get a civilized country just by moving to it. You have to work for it. Why should any country that has produced civilized systems want to accept newcomers who come in as free riders without any will to work on maintaining civilized systems? It’s one thing when people are refugees, actually fleeing for their lives, but who wants an immigrant who isn’t willing to do the hard work of citizenship?

  5. Anne

    How is it not obvious how fragmented and dysfunctional the system is? What should be driving this is one, simple question: “Are you human?” Everyone who can answer “yes” should be entitled to care under one uniform, streamlined, system. One that minimizes overhead, is not constantly working to maximize profit at the expense of care, and does not require a degree in insurance-speak or wading through an inches-thick, small-font “booklet” in an effort to determine what is and isn’t “covered.” None of the “in-network,” “out-of-network” traps that could find you opening gigantic medical bills in the aftermath of your care. No more barriers to care as exist in the current system – and that’s what co-pays, deductibles and premiums are.

    My niece, who will be 24 in March, was just diagnosed with MS, and for now is being covered under her parents’ plan. I’m pretty sure the various drugs they will want her to take are hideously expensive, even with insurance. She wants a family, she wants a life, and has no idea how or if her disease will progress – but the medications are designed to slow recurrences/relapses, which is important because no one knows where in her brain the next episode will occur, and what body systems will be affected. That is stressful enough without fearing that the cost of keeping this thing in check will be more than she and her parents can afford.

    It’s not that we can’t have a good, workable, affordable system – millions of people in other countries have it, so we know it can be done – it’s just that we’re the exceptional country that places money and profit as a higher priority than the health of our people.

    1. Bryce

      Tell your niece I wish her the best. I also have multiple sclerosis and it has been nothing but a nightmare. I have aggressive RRMS (males tend to get MS less than females but it tends to be more aggressive for males than females) and after 2 relapses (was misdiagnosed my first relapse) my disability score is already a 3 or moderately disabled. You can also tell her that there is a great community on Reddit if she wants to join 4,500 other MS’ers. We can answer any questions she or family members/loved ones have about the disease. We are also there to provide support while allowing people to vent. MS is a confusing disease and is downright terrifying for many since it hits us in the prime of our lives.

      My first relapse was at 28 and my second relapse was at 32. I had to drop my private insurance company because they didn’t approve the MS drug (rituximab) I wanted. I am now on Medicaid and am very thankful for it since I am actually getting the treatment I want now. Medicaid has been a breeze compared to the hoops they make us and doctors go through with private insurance. I want to see Medicare for All since we would all save a boatload of money while getting rejected less for procedures and medications. People also rate Medicare much higher than private insurance companies, but I think we all know if people were in charge of this country we would have Medicare for All already.

    2. Bryce

      I forgot to say it too, but there are drugs that can halt MS. We have Lemtrada, Tysabri, and Rituxin/Ocrevus (Ocrevus won’t get approved for a few more months.) which can all halt MS. I don’t know if your niece is JC Virus positive, but if she is you can count Tysabri out. We will know in about another 5-10 years if these drugs will be a “cure.” I put “cure” in quotation marks because people in the MS community don’t even know what a cure should mean. We also need more data since it would be nice to see if these drugs stop all relapses and brain atrophy for 25 years. Lemtrada can actually reverse disability in some MS’ers but it causes thyroid problems in about half of patients. So we do have drugs that we think will halt MS for life, but we need more time to start calling any drugs a cure for MS.

      I will assume you are from America so this is where these drugs apply to you. It is tough to get on these drugs until your niece relapses another two or even three times due to her neuro and insurance company. Some neuros start treating the most effective drugs first since MS is a debilitating disease, but it will be a battle with most private insurance companies. It’s not a problem with Medicare/Medicaid. Some neuros don’t even prescribe the more efficacious drugs until she relapse, which sucks since that means more brain/spinal cord damage occurred. I agree with treating MS’ers with the most effective drugs first even though they are the riskier. These drugs are considered riskier due to their possible severe side effects. However, that might change with Ocrevus since that drug is far safer than Lemtrada or Tysabri. So in America, we mostly treat MS using the safest drugs first but they are also the least effective drugs. Then after a second relapse she will go up to second-line therapy drugs like Gilenya. Lemtrada/Rituxin/Tysabri are all third-line therapies and these are the drugs that will most likely end up halting MS in its tracks.

      In most European countries and Australia, they start with third-line therapies since they are the most effective. I think the US will start prescribing Ocrevus the most since it could be the most efficacious drug while being one of the safest drugs. I would also tell your niece about the benefits of exercise, meditation/yoga for stress reduction, and Ocrevus approval coming up. To me the risk of having MS offsets any risk in stopping MS in its tracks. First and second-line therapies only slow MS disease progression which seems cruel to me. In theory with Ocrevus, she could only end up having one relapse, never progress to secondary-progressive MS or SPMS, and stop her brain from shrinking at 2-7x normal brain atrophy rates. Barts MS blog is also another great sight if you want to keep up on the research coming out of the MS field.

      1. Anne

        Bryce, thank you so much for this information.

        Brain scans and MRIs revealed older lesions, so the symptoms that brought her to a neurologist were not her first episodes; I don’t know if this means she will be treated as already having multiple relapses.

        I suppose the good news is that because her mother has connections with Johns Hopkins, she is in the process of getting an appointment with the MS Center there – all of her tests have been sent over and will get reviewed, she will see someone there and a treatment plan established. We live in the area, so are fortunate to have Hopkins as a resource.

        Because she is young, and wants to one day have a family, I expect one of the discussions will be identifying medication that will allow her to one day do this, and also do the best job of slowing/halting the progression.

        I will definitely pass on to her the info about the Reddit group – I think it would be helpful for her to have an outlet for asking questions and expressing herself with people who are going through this.

        She is an otherwise healthy young woman, to all appearances experiencing no difficulties, so at this point, I think it’s hard for her to wrap her head around all of this.

        I worry that she has a tough road ahead, not so much with the disease, but with navigating the insurance aspect and affording the cost of treatment. This is all just so wrong; it’s bad enough to have to deal with something like this – the stress and worry of being able to get the treatment one needs doesn’t help.

        Again – thanks for your good thoughts – and best of luck to you in your own battle with this.

        1. Bryce

          It should be treated as her second relapse at a minimum. I don’t know how many lesions she has or the locations, but that will also be an indicator of how her MS will progress. Who knows, it could even be her third or fourth relapse, but the neuros most likely won’t be able to tell. MRI’s also miss microlesions, or lesions smaller than 4 millimeters in size. Lesions on the spine or brainstem are never a good thing either. If she is black, it also means that statistically her MS will be worse. All these things should be taken into account when determining what drugs she should take.

          I would have her make a list of all her questions along with all of her goals that she wants to achieve out of her MS drug therapy. For example, does she want to halt MS or slow it down? One bad relapse and she could lose the ability to walk for the rest of her life so it is something to think long and hard about. How does she feel about the risks of MS vs. the risk of MS drugs? How do her neuros feel about treating aggressively from the start? Does she want to have to give herself shots every few days for the rest of her life that reduces disability progression, take a daily oral pill for life that reduces disability progression, or something like rituximab which is an infusion every 6 months for years which halts the disease? I am assuming that she has relapse-remitting MS (RRMS) and she has had a good recovery after the first relapse. However, she is now had at least her second relapse which most people still recover well from. I doubt she is already moderately disabled like me after two relapses…well at least I hope she isn’t. It’s the third relapses and on that cause a lot of disability progression. This entire time since her brain is also shrinking at a much faster clip than health people so that needs to be stopped ASAP. There’s a good chart at the link below showing you the progression of RRMS:

          There are some tricks to help her getting her drugs covered. Most MS drugs the companies will pay for her out-of-pocket costs, so they won’t be a problem. I would have her talk to an insurance broker (doesn’t cost her anything) so she can get the best healthcare plan for her. If she has employer health insurance or is still under her parent’s insurance, she can still get MS drug financial assistance. For example, she could get a $6,000 max out-of-pocket plan (since it is cheaper) and her MS drug company will pay the $6,000. After that, everything will be covered 100% so the cost of MRI’s, doctor appointments, physical and mental therapy, will cost nothing for her. Usually, the trick is to get the medicine right away in her annual billing cycle so the drug company pays for it and everything else she needs will be fully covered after that.

          There are all sorts of tricks for us MS’ers to avoid the true costs of these drugs, which of course falls on the rest of society to pay. MS drug costs are soaring and the average treatment now costs over $60,000 per year. MS costs over 3 million dollars per patient in terms of drug costs, healthcare costs, and loss of income. Try to do everything you can to convince her that halting this disease should be the number one goal. As soon as a person has a disability score (EDSS) of above 3, our unemployment rate is 50%. This is why Europe and Australia chose higher risk drugs that are more efficacious because MS eventually destroys lives. A person really starts to lose their quality of life as disability accumulates. If she can halt her disease, she will lead a normal life and at least be able to work towards her goals of having a family some day.

          Learn the ropes of healthcare insurance and it will be of little concern. MS should be your #1 concern so learn how best to take advantage of these MS drug programs so she can focus on her health and not her health insurance. Let her know that exercise and stress reduction activities (yoga, meditation, etc.) are her best friends right now. If you have any questions, feel free to use me as a source. I have been learning about MS for the last 18 months and I am full of information and willing to help when I can. My email is should you need anything. Here is a link for MS drug financial assistance programs:

    3. Mikerw

      Ugh, best of luck. Our 24 year-old daughter has been in a battle with Crohn’s disease for over 12 years. As with all autoimmune diseases it is incredibly corrosive to both the body and spirit, as well as those in her family. I could recount story after story fighting to get her medications and surgeries paid for. This is the norm.

      Simply put, the drugs used for these diseases are insanely expensive. One drug she takes (and they use many of the same drugs across the autoimmune disease spectrum) is $18,000 per dose every four weeks. We fight every month with the insurers, as it has to come from their pharmacies.

      The night before a major operation we actually had a supervisor at Unitedhealthcare tell us their policy is to deny all coverage above a certain dollar level and then make you fight for payment (this is with both us and her surgeon’s office on the phone) despite it being covered in the policy. RICO charges anyone?

      Your family will encounter some amazing and highly dedicated medical professionals along what will likely be a challenging journey. Enlist them to help you get the benefits your niece is entitled to. They will likely have a patient advocate who knows how the system works and you will need all the help you can.

      This is the real story of our “healthcare” industry. It was designed to extract maximal profit and in that regard it is a staggering success.

  6. BeliTsari

    Well, WalMart’s Happy Hospice Area & McOrgan Transplant Centers will indeed offer us useless, parasitic olds jobs to pay-down some of our burdensome “final expenses,” not covered by reverse mortgages & Rent a Senior sharing economy gigs and other GOP protoplasm recycling centers? Der Marktplatz Macht Frei, after all? Beats the heck out of flying us all to the Middle East, totting our own firearms, rations and uniforms!

  7. JTMcPhee

    In 2015 we spent $3.2 trillion on health care,” blahblahblah

    I know “we” need some term to label the Thing that is Eating Us, but please, IT IS

      1. polecat

        What is it ?

        An inducement to die impoverished …. from just another rent extraction machine … aka ‘Farengi Deathcare’ !

    1. reslez

      Maybe it would help to break out which % of the $3.2 trillion is actually spent on health care and which is allocated to overhead, fraud/waste/abuse, yachts for health insurance executives, and private planes for hospital administrators.

      1. Mel

        I read an article on the Internet that said

        Of the $3.2 trillion health spending, 70 percent goes directly to fund the cost of our healthcare. The remaining 30 percent is spent on administration and profit, which is more than twice that of any other nation. In 2014, studies published by the Institute of Medicine, Rand Corporation, and the Center for Medicare/Medicaid Services estimated that out of total health care spending, as much as $900 billion, or about one third of our total spending, can be attributed to waste, fraud and abuse.

        1. human


          Using these figures at face value; If one third is attributed to waste, fraud and abuse and another third to overhead and profit that leaves (use pencil and paper if necessary …) one third in actual payments to health/medical care providers, or just over $1T per year, about 6% of GDP!

  8. juliania

    I’m a bit sad at the tone of this posting as it begins, Lambert. The facts you put forward about medical care in this country are excellent, as are the points you’ve put in yellow – I totally agree. But to call the inauguration in question at the getgo, and then say far right positions are inevitable – well, again you could well be correct, but if we are going to persuade those who I personally very much hope will have a smooth transition into office to our views, is this really the way to go about it?

    I hope I’m not sounding too harsh; I’m just a bit disappointed because it is a very good post once you get beyond the first part.

    1. reslez

      You seem to be arguing in favor of giving Republicans the benefit of the doubt. I think past history proves them ineligible for such niceties. As are Democrats IMO.

    2. Vatch

      One can make such judgments based on the track records of the people whom Trump has nominated for cabinet level positions in his administration. Which of his nominees so far are likely to change the healthcare system and the healthcare financing system in the U.S. for the better? Do any of his nominees give you the sense that he cares about helping anyone besides large corporations and extremely rich individuals?

  9. Linddan

    A single payer system based on Medicare for all is the solution. As long as we have politicians waiting to be paid by healthcare lobbyists it won’t happen.

    1. schmoe

      This would actually make the lobbying problem worse since there will be enormous pressure (campaign contributions) to raise reimbursement rates. Look at the debacle that is Medicare Part D, which included a provision that Medicare can’t even try to negotiate lower drug prices with Big Pharma – note also that the media, other than a 60 minutes episode – has been completely silent on that issue. On an unrelated matter, I wonder how much Big Pharma’s advertising budget is.

      1. Carla

        Lobbyists wrote the Medicare Part D legislation and the Affordable Care Act. It is impossible to make lobbying worse. We need a functioning federal government — something we Americans have given every evidence that we are utterly incompetent to achieve.

  10. sleepy

    Balance billing for medicare will be one more way to tack on another layer of private insurance to the medicare mix. Presently, I have a Blue Cross medicare supplement and a Humana prescription plan D. With balance billing, there will either be another private policy supplement to purchase–“Balance Billing Protection”–or the coverage will be incorporated into the existing medicare supplement and the rates will triple.

    This of course assumes that the insured can afford the additional premium costs. I would not be surprised if within 5 years my total medicare and private supplemental premiums will equal what I was paying last year on a Cobra plan, pre-Medicare—-$550/month.

    1. Knot Galt

      Nina Turner, former Ohio State Senator. How will Our Revolution get us into single payer now that is taking contributions from the 1%?

  11. cocomaan

    I don’t see a path for Republicans to repeal Obamacare. Put aside the 30 million people losing coverage for a second.

    Obamacare also introduced ICD 10 and other billing requirements to the mix, among a billion other unfunded mandates that need to be complied with. Doing that required building a lot of custom systems to be built in these institutions. A lot of beltway bandits made a lot of money on that kind of software parasitism. From talking with people in healthcare, reversing Obamacare means they are in software hell at a time when belts are already tight.

    It’s eleven million words long. The law was designed to be impossible to repeal.

    In fact, I’d say that dropping 30 million people is less of a problem. People are being dropped off welfare rolls, particularly SNAP, all the time now. Many of the people on Obamacare don’t even use their coverage and get it to avoid a penalty

    1. Benedict@Large

      The path is starting to become obvious. They will pass something they can call a repeal, but which leaves more damaging provision off until after the 2018 elections, and the most onerous of all for after the 2020 elections. The problem they are having with this is the exchanges. Insurers are simply not going to commit to the exchanges if they think they won’t be around in a couple of years. In this aspect at least, ObamaCare is proving to be quite resilient to repeal.

    2. Yves Smith

      You seem to have missed Lambert’s many stories on the software mess when Obamacare became effective, and how much the insurers were doing manually. Operational problems are no obstacle to implementing bad health care policies.

      1. dw

        think its more a political time bomb, sine so many that voted to get rid of it, dont know they use it. but will when its gone.

        and it once Congress has ‘repealed’ it, even if its delayed. it will die. insurance companies wont participate it if it wont be around for years (aka decades).

        what i never ever understood was why insurers wanted in the first place. or why they fought it . the policy holders in question, arent good risks, and arent very healthy. they are just going generate claims. sort of like the elderly. which they abandoned 40 or more years ago. i can see why providers might complain (but then they will about insurers too) so its mostly moot there. but then you have the drug industry. they have every incentive to keep our ‘health care’ system as messed up as it is. cause they increase prices 500%, have a minor slap on the wrist by Congress, and agree to lower their prices so the increase is only 250%.

        while the software for the exchanges was far from perfect, there never really has been any large application built that has been. but then this was another out sourced monstrosity, to the lowest bidder (which is no different than how its done in the private sector too. with about as good results. just not the publicity to go with that)

  12. Disturbed Voter

    The path for young people to get medical care is to join the military.

    The path for jettisoning Obamacare is to suspend the individual mandate at least, and the employer mandates. Then if you like your Obamacare … you can keep it, or go buy a private plan. If you don’t like either, you can take your chances, and not have any health insurance (unless you are in the military or some other legacy ghetto like the police or fire department).

    The whole WW II gimmick of employers providing a health insurance plan is over.

    1. marym

      It’s not clear to me if your comment is meant as a recommendation or a prediction. That would be the key if the goal is to get rid of, or greatly diminish, a very flawed program and replace it with nothing, further reducing the number of people with access to affordable health care. Usually the goal for people commenting on this topic here is expanded or universal access, though.

      1. hunkerdown

        There’s a little more to life than health care. The aim is to at least recover a status quo in which insurers do not have an enforced income stream from us to use against us — from which we can try again, this time with the hindsight of who was pulling what when ten years ago.

        Democratic faithful are far too willing to accept “fixes” in the form of parliamentary performance. Worse, I think some of them get a bit of a thrill from it.

        1. marym

          I first noticed when the ACA was passed, later realized that wasn’t the beginning, that if something bad, or something far less than as good as it should be, is passed, this is celebrated as “now we must…” or “now the Democrats must…” etc. – my first intimation of what Lambert describes as “fighting for” but never winning. It’s just a cover for “we got through that one without making it disappointing the donor class.”

          1. Carla

            Yes, marym, the first clear instance of this I recall was when Bill Clinton began his presidency by ending “welfare as we know it.” Little did we realize he and Hillary would end “healthcare as we knew it” and “banking as we knew it.” When you think about it, they really accomplished a lot. Remarkable people, those Democrats.

            1. Disturbed Voter

              This is what happens when there is no truth in labeling. Democrats acting as Republicans or Republicans acting as Democrats (see Nixon). Destruction Capitalism is now a bi-partisan thing … but a fearful thing, hence the rejection of Romney who was a vulture capitalist.

              This is a Silicon Valley idea … that you outcompete yourself, before your competitors can do that. Unfortunately like in the case of Osborn .. this can be so mishandled as to be organizationally fatal ;-( Like avoiding being nuked by the USSR, because the USSA nuked itself ;-(( See the movie Failsafe.

          2. Disturbed Voter

            This is a more general pattern. In the EU … the idea of the Euro etc is that once in, and once entangled, Europe has no choice but to become a super-state under Franco-German leadership. And this wouldn’t have been a bad thing, except Franco-Germany has failed in its program, because of short sighted politics. This is why Brexit.

      2. Disturbed Voter

        Purely practical politics … not idealism. One can propose universal health care if one wants, but that is separate from fixing the immediate problems with Obamacare. Personally, I feel that health insurance of all types is a scam … unlike say life insurance … because the demographics of life insurance is predictable with actuary tables … it is a reasonable betting system. The use of health care, and thus the draw on health insurance funds, isn’t like that. With life insurance only one claim can be made … and usually life insurance doesn’t change demand, it doesn’t encourage suicide. However with health care, the very availability of it creates a dynamic demand … the more you provide, the greater the demand. It is a poor bet by the health insurance company, that is met by ever increasing premiums … it is a ponzi.

        1. Carla

          “However with health care, the very availability of it creates a dynamic demand … the more you provide, the greater the demand.”

          This is a shibboleth. If it were true, all those countries offering universal health care would have per capita costs even higher than ours; instead, they are about half of ours.

          And furthermore, their results are better: their average lifespans continue to increase, while ours are falling. Their infant mortality rates are falling, while ours rise.

          “In the public interest” is a meaningful concept in much of the rest of the world. It never had much currency here, and what little it attained has been swept away.

          1. Disturbed Voter

            The reason why Europe can offer free anything, is because of Nato and fiat petro-dollars. That is the problem with country X has it by country Y does not. It is because of more than just “we hate our own citizens” and “we are misers”. The problem remains, if you actually had a flat playing field, could Canada/Europe afford anything, other than Russian occupation?

            1. Yves Smith

              Huh? “Petrodollars” is urban legend, although some people in the military-industrial complex use it as an excuse for our imperial project.

              And countries that are not in NATO provide for universal or a very well designed public system with private supplements, namely the Nordic countries, Australia, and New Zealand.

              And Europe would be in vastly better shape if the Eurozone didn’t have its horrid Maastrict budget rules…


                This is an opportunity to thank you and others … for the best political-economics web site.

                In political-economics, politics directs. Unless you are LBJ, you can’t have your military cake and eat your domestic economy at the same time. With peace, a lot of things are affordable. The people cry “peace, peace” but there is no peace.

                The EU is an attempt at building a second USA … it isn’t possible. Like Chancellor Bismarck commented when asked what the most important event of the 19th century was … replied that N America spoke English.

        2. human

          Insurance of all kinds are a social(socialist) construct: The many pay the misfortunes of the few.

          For a small fee your family, or fiduciary relationship, is compensated for your death. A statistically measurable probability approaching (and ending) at 1.

          For a percentage of agreed value, based on statistics, history and conditions, a property loss is reimbursed to its’ owners.

          When a loss is certain to happen sooner than later and can be further ameliorated by continuous vigilance and/or intervention, which some insurance does indeed require, payment requirements can become extremely complicated. These contracts could be more easily recognized as maintenance agreements, as in HMO’s. Compensation through an insurance contract is no longer an easy fit. The many are no longer compensating the few for losses as there is no longer “the few”.

          In a private system, administration becomes an excerise in maintenance of itself.

          1. Disturbed Voter

            Exactly. But with HMO (private or public) trying to contain costs, it cuts both ways. Not just with vendors like drug companies, but with patients. We can avoid most medical costs by establishing a Health Dictatorship … no illegal drugs, no tobacco, no fat, no sugar, no salt, no caffeine … and mandatory 5K runs and pushups every day. We can also cut costs by doubling down on Logan’s Run, by executing anyone who survives to their 60th birthday, or who becomes an excessive burden before then. This is the logic of a price system, rather than a humanitarian system. Minimizing costs and maximizing prices .. requires totalitarianism.

        3. marym

          Calling “temporary Medicare” a “transition” without any affordable, effective alternative means nothing, except maybe a divisive attempt to keep a few people a little less desperate for a little longer.

          As Carla has pointed out, there are actuarially sound implementations of universal healthcare all over the world. Medicare for All or VA for All, funded through progressive taxes, subject to sound bargaining rules with providers, and kept out of the looting clutches of the privatizers-for-profit, can also be a sound program for the US.

          1. Disturbed Voter

            1. I was only addressing politically realistic short term solutions. Long term one could do Medicare for All or VA for All, funded thru progressive taxes, with sound bargaining rules against the drug companies and the AMA.

            2. As per my response to Carla above, while there are actuarial positives to better heath, social benefits beyond personal benefits … the problem is apples/oranges comparison with Canada/EU. It is easier to afford this (at least in the medium term, before the underlying dynamics overwhelm it) if we drop most of the US World Policeman policy.

    2. reslez

      > The path for young people to get medical care is to join the military.

      Sadly about 75% of young people are ineligible for military service. Besides, given the unethical garbage we give our military to do, is it really a good idea to tell our young citizens it’s their only option for health care? Also, you may be operating under the mistaken assumption that military service = health care for life, which is far from the case.

      > The path for jettisoning Obamacare is to suspend the individual mandate

      You’re leaving out a lot of important details such as the minimum mandatory coverage required by Obamacare, which regs to keep in place, which to repeal, whose rice bowl gets smashed (always ours), etc.

      > The whole WW II gimmick of employers providing a health insurance plan is over.

      Sure looks that way. Let’s just do Medicare for all.

      1. Disturbed Voter

        You are correct about ineligibility. Transition for people on Obamacare, can be provided by temporary Medicare coverage. And yes, the easiest way to universal health care, is Medicare For All. One has to decide if one an afford that or not. The mathematical instability of medical insurance applies to the government as well as private insurers. It is a ponzi scheme, in a way that say Social Security isn’t. With health insurance of any type, demand increases with availability, leading to ever increasing expenditures. With Social Security, it is funded by the taxpayers, and not all live long enough to make a claim.

        1. Carla

          “With health insurance of any type, demand increases with availability, leading to ever increasing expenditures.”

          If this were true, other countries that have universal coverage would be paying much more per capita than we do; instead they pay much less, in many cases about half what our expenditures are, and with better outcomes.

    3. dw

      jettisoning the individual mandate by it self will terminate ACA. no insurer can provide policies to those who will make claims. and they are private plans from insurance companies they are just so9ld on an exchange where the buyer can actually compare plans (which you cant do without the exchange), not the government. and the private individual plans pre ACA, were mostly either so restricted it what they covered, or very expensive, or unavailable.

      if you didnt get coverage through your employer (or Medicare or Medicaid or the VA), your odds were not very good to get much care, if any. mainly cause you were denied, or you couldnt afford it.

      and you know why employers provide health benefits right? or do you?

  13. Synoia

    In 2015 we spent $3.2 trillion on health care, which was $10,000 per person in the U.S., ($25,000 for a typical American family). This is 17.5 percent of the U.S. Gross Domestic Product (GDP).

    And the so called efficiencies of the “Private Sector” do not apply for monopolistic rest extraction.

    Now, I don’t know why Lamm and Markovchic don’t just lower the age for Medicare eligibility from 65 to zero, like Teddy Kennedy proposed.

    Because it punctures and extinguishes the central myth of the United States:

    Private Enterprise can serve consumers better than government.

    Which they cannot because the Government’s objective is to serve people, and large private enterprise’s objective to extract rent from people.

    Private enterprise’s objective is to investment to make a return on investment of over 40% a year (A playback period of under three years), using the commons provided by the Government:Schools, education, roads, police, etc).

    Government’s objective is to invest with a expected payback in 20 years, by investing and building the commons, Schools, education, roads, police, etc.

    The taxes paid by business in no way at all have payback period under three years. For example: education is a 20 year investment by parents, (taxes, schooling and university costs) with NO expectation of return by the parents of the children.

    This complete focus on profit is disgusting and dishonest, and was considered a mortal sin less than 300 years ago.

    It is worship of mammon. I fail to understand how a significant part of the US’ population believe themselves to be devout Christians. A short reading of the beatitudes, with a modern day comparison is instructive:

    Blessed are the poor in spirit:
    Blessed are the Rich

    Blessed are they that mourn:
    Blessed are they that don’t have to.

    Blessed are the meek:
    Blessed are the arrogant

    Blessed are they which do hunger and thirst after righteousness:
    Blessed are they who lie

    Blessed are the merciful:
    Blessed is warmongering, the death penalty, and punishing victimless crime

    Blessed are the pure in heart:
    Blessed are they who cheat and steal

    Blessed are the peacemakers:
    Blessed are the warmongers

    Blessed are they which are persecuted for righteousness’ sake:
    Blessed are they who persecute

    Blessed are ye, when men shall revile you, and persecute you, and shall say all manner of evil against you falsely, for my sake.
    Blessed are they who lie and cheat for power’s sake

    Everyone expects a Christian way of life from a Christian. They want to see in him an example of non-hypocritical faith, honesty, a spiritual attitude and love. On the other hand, there is nothing sadder than seeing a Christian who lives only for worldly, mortal interests.
    What’s the bottom line?

    I assembled this in 2006, when I had hope for change.

    1. FluffytheObeseCat

      This is great. I would amend the last two updates however, as follows:

      “Blessed are they who persecute for conveniences’ sake,

      Blessed are ye, when men shall adore you, and suck up to you, and shall say all manner of good about you falsely, for power’s sake.”

      We can print them all together and publish them as “The Trumpitudes”

  14. bob

    All we have now is a price floor. The price has been set with the ACA.

    No benefit was set. All that was ever set was a price.

    That’s the frame. These fuckers now believe they are entitled to that price floor, plus jets and bonii. Shareholders are also entitled to a growing dividend, because markets.

    Dems, being reasonable, and completely conformable with taking massive amounts of cash from Heath insurance companies, will start bargaining above the floor, because markets.

    I can’t think of a better way to set up a giant, public/private feeding trough for the pigs in DC. Every dollar the health insurance industry gets now can be used to perpetuate their hold on power.

    1. Disturbed Voter

      As pointed out by Synoia directly above … universal health care demands a partial repudiation of the … central myth of the United States … that private enterprise can provide for all needs, that government is unnecessary. What is sufficient, is that people recognize what private enterprise is best at providing, all else must be government provided. A mixed economy that prefers private enterprise when reasonable. Obamacare is an unreasonable collusion between private enterprise and government, it is fascist.

  15. Dr Duh

    Here’s the counter-argument in favor of balance billing…

    They are a pure hospital service that is contracted with the hospital with no ability to choose patients. If a surgeon books a case, then a member of the anesthesia group staffs it as per their agreement with the hospital. When it’s a gang-banger or an uninsured drunk driver or guest worker, then everyone from the hospital on down gets paid either de minimus or zero. Fine. You cross subsidize that with your paying customers. But if anesthesia can’t choose customers and doesn’t have the ability to balance bill, then they have to take whatever rate the insurance company offers them. If they refuse to contract with the insurance company then they have to take the rate anyway.

    Guess where that’s headed? Instead of having your anesthesia done by a physician who graduated at the top of their class in college, went through four years of medical school, then did four years of residency, you get a nurse anesthetist who went to nursing school, did a year of critical care nursing and then two years of CRNA school. Guess what kind of cases CRNAs train on? Hint, it’s not the 400 pound guy with no neck going into shock while necrotizing fasciitis eats his groin, nor is it the multiple GSW who chews through 40 units of blood, nor is it the eight year old who is losing her airway.

    The difference between a CRNA and a real anesthesiologist is not a gap, it’s a chasm. You can get away with second rate support on the other side of the blood-brain barrier fine until suddenly you can’t. If you’ve only done the kind of cases that go smoothly 99% of the time, then you’re unprepared for when disaster strikes in that 1%.

    I’ve worked with some good CRNA’s and I’ve worked with some dangerous ones. The thing about the dangerous ones is they don’t know what they don’t know and so go blithely forward with misplaced self-confidence. As a resident I had fights with CRNA’s who didn’t want to call an attending anesthesiologist into the room while the patient’s oxygen saturation was tanking because they wanted to ‘try one more thing.’

    When it came time to choose where I practice; who helps me fulfill my promise to take care of the patients who’ve entrusted me with their lives, I made sure that it was a hospital where anesthesia was delivered by real anesthesiologists. It gives me the confidence to focus my full attention on my part of the operation.

    You are welcome to make your own choices.

    1. ambrit

      You are missing the central point of the “balance billing” program. This program is designed to extract the maximum amount of resources from the “covered” population. Once that extraction process is complete, the “covered” population is sacrificed through the denial of care directly stemming from the “balance billing” process.

    2. human

      A well-argued point, however, balance billing should not be a discussion at all as the article is concerned for those who forego medical care altogether because of its’ cost.

    3. Cojo

      I think your argument is less in favor of balanced billing (I’m not even sure how it even pertains towards balanced billing) and more against discombobulated fee for service medicine. You state that somehow there is a connection between whether you receive an CRNA vs an MD with whether you are insured or uninsured. In my experience (working MD) the decision of CRNA vs Attending is based on acuity of care and patient substrate.

      Medico-legally, it is up to the CRNA-MD team to decide which patients/procedures can be safely handled by CRNAs and which need the full attention of an MD. If you are making these decisions solely on ability to pay, that is ethically questionable at best and exposes the group to liability should something go wrong where a less qualified provider is selected solely based on whether the group is expecting to get paid.

      Now, perhaps your argument is that when a large enough percentage of your patients are unwilling or unable to pay therefore the group has to either overcharge honest paying patients or substitute MD anesthesiologists with more inexpensive CRNAs, you’ve mated a compelling argument for single payer/universal coverage where the ability to pay does not play into the decisions on quality and quantity of care.

    4. J

      We were a mid sized, all physician anesthesia group on the west coast until two years ago. Unfortunately, due to declining physician reimbursement and a changing payor mix that I’m sure you’ve experienced too, our group’s hospital stipend had grown to a number the administrators just couldn’t stomach anymore. We ended up going to a mixed model with physicians handling cardiac, peds under 2, major trauma and other complex cases solo while we supervise midlevels in usually a 1:3 arrangement for most other routine cases. There’s a lot more staffing headaches due to multiple issues with using nurses, hasn’t really been the clinical Armageddon we thought it would be. As the mid levels are our employees and we retain our contract with the hospital, we keep our autonomy and call the shots. I think the worst of all possible worlds would be an employed physician of some AMC – I would stop practicing in that situation. Sure, I enjoyed doing all my own cases myself, but times are changing.

    1. flora

      adding: from the above link. (2014)
      “The compact’s unofficial “reference” federal block grant for Kansas was $6.985 billion in 2010 and for Missouri, $18.669 billion. Those estimates reflect spending for Medicare and Medicaid in the states.”

      Considering how large is the budget hole in Kansas, giving the state another block grant would likely see a large portion of it used for other than health care. Already the state has stripped the highway fund and has talked about selling off the tobacco settlement funds (used for childrens health program) to raise quick cash;

      Kansas privatized its Medicaid program a couple of years ago and the results have not been good.

  16. Herkie1

    Of the $3.2 trillion health spending, 70 percent goes directly to fund the cost of our healthcare.

    This is where every single thing I have ever read about healthcare in America goes off the rails. Our system of private for OBSCENE profit care has no REAL cost. I am not saying that there is no cost, I am saying all the PRICES and fees and charges and billing are plug numbers made up by those who deliver the services.

    Providers decide just how much of the economy they wish to grab with both fists and then they bill twice as much to achieve that goal knowing they will be lucky to get half reimbursed to them.

    As long as healthcare providers are setting prices for their services you will NEVER control “costs.” And for a party that says it HATES unions the GOP has nothing but good things to say about the AMA which is a government unto itself, it regulates med school admissions and dictates care policy in this nation, artificial shortages are the rule, and private insurers which add nothing to care but pad the cost by 30% are their baby. They invented it.

    Funny how NOBODY will claim to like socialized medicine in the USA, but it is just as much, nay more of a public good as roads or schools. And for the top 10% of us for whom cost is no object the current system does work perfectly. For everyone else any contact with the system will mean a one way ticket to US Bankruptcy Court should you ever have any REAL health problem.

    I am one of the lucky ones, in good general health and exempt from the ACA requirement to buy insurance for the greediest people that ever lived. I have as a 100% disabled veteran the VA for my provider. Of course in Donald Trumpistan the GOP congress plans to SLASH all veterans benefits and turf our care out to private facilities and providers, this in spite of the fact that while expensive our care is still the most cost effective in the country at $2,200 per veteran.

    Trump and the GOP congress plan to gift private facilities with at least half the billions spent while reducing the number and quality of care veterans get. Far from making veteran care cheaper it will make it VASTLY more expensive. They see the VA as a communist and un-American institution simply because by not making a profit it deprives the wealthy of ever more wealth.

    If you thought any particular race or gender, or the NRA, or any of the other special interest groups in the USA had the power to scare the wits out of politicians just you wait till they mess with the veterans.

    Veterans have special healthcare needs and are prohibited by law from filing suits for injuries. We also have in the VA system a patient Bill of Rights which no private facility or system provides. Such things as our right to have input in our treatment plans is something you do NOT have if you are not part of the VA system. Wait times have made headlines at the VA, and some facilities in some specialties are overbooked often, but that will be NOTHING compared to going for private care and getting in line behind 175 illegal immigrants at the ER in the community because they have no other providers. When veterans see what wait times are like in the private community they will weep for the wait times they had at the VA.

    I have said since the late eighties that healthcare costs would bankrupt the USA one day and viola, we are there. The ACA fixed nothing, it made people appear to be insured on paper, but with ghastly confiscatory premiums, limited services covered, and gigantic deductibles, those newly insured could afford to get sick or injured even less than before, and worse now they cannot even afford to be well. The ACA was nothing more than a tax on good health. And the irony is that it is the best solution anyone has yet come up with. Because a NHS or universal Medicare is politically NEVER going to happen here, I am convinced we would have civil war first.

    The we see little poverty stricken communist Cuba where 99% of the population is happy with their universal care, and which costs less than the USA pays for flashlight batteries. Yet, it has better care outcomes than ours, lower mortality rates, longer lifespans, lower infant mortality, they even have a cancer vaccine the USA has not approved but which 40 nations have. The difference is of course they have no AMA, they allow anyone who wants to a right to study medicine. People who become doctors and care providers are doing it not so they can make millions per year but because they love medicine.

    This is the single hardest truth of all, healthcare is not OPTIONAL, it is a basic and fundamental RIGHT! The only reason it is not treated as such is because of the ungodly vast near insane greed of the care system. We will not get control of healthcare till we unceremoniously slash out the greedy and make universal care a right. It might not get done in my lifetime but it WILL get done because the exponential rise in charges will not abate till the entire economy is destroyed. Unfortunately doctors feel entitled to make as much or more than any other profession including banksters and politicians. They should do what they do best, sell used cars and let people who actually CARE about others to do the medicine in this country.

    1. run75441


      Thanks for explaining the VA to them as it saved me the trouble of doing so. I go to the VA and my appointment times there are far less than Commercial Healthcare for which I am also eligible. I like my PC doctors in both places although my VA ones change out every 3 years. I am happy with my VA care.


      “As long as healthcare providers are setting prices for their services you will NEVER control “costs.” And for a party that says it HATES unions the GOP has nothing but good things to say about the AMA which is a government unto itself, it regulates med school admissions and dictates care policy in this nation, artificial shortages are the rule, and private insurers which add nothing to care but pad the cost by 30% are their baby. They invented it.”

      is called the ChargeMaster fees. It governs at hospitals too. If you do not have healthcare insurance, you are billed at the ChargeMaster fees or “List.” Try asking a doctor at a Commercial Healthcare facility how much and you will get a blank stare. They do not know.

    2. weinerdog43

      Thanks Herkie. Great explanation. Even though i work for a Fortune 100 company, (and an insurance company to boot), our healthcare is simply craptastic. The deductibles are so high, and the balance billing so excessive, the best option is to simply avoid the medical/industrial complex as much as possible. While I’m fortunate enough to be currently healthy, as you point out, healthcare is not optional. Eventually, we all get sick and die. Sometimes, some folks get really sick, and they are just hosed under the current system. It is completely the luck of the draw.

  17. Marcie

    I’m totally disabled and NOT on Medicare by choice. One of the main reasons is Medicare will pay for the most expensive drugs, the most toxic and risky scans, the most invasive surgeries but they won’t pay for what will get me well which is chelation. I was just discussing this with another poisoned victim. Medicare is going to pay for stem cell replacement but do nothing about the massive amounts of gadolinium she retained after MRIs with gadolinium-based contrast agents.

    What many don’t understand is if you go to a mainstream doctor you will get what is profitable for them, not what you need. The cartels ensure this is the case or the doctor will be attacked and lose their license to practice. If and when you need a remedy it will be the remedy that brings them the highest profit whilst killing the patient or maiming them for life. A tiny percentage of those injured are able to sue so families go bankrupt or lose their life savings and their home not because insurance refused to pay but because they did pay for you to be harmed.

    Over 400,000 patients die a year due to preventable medical error. Is that a system you want to go to? The medical and pharma cartels control what treatments we are allowed and the reason I stay away even though I have the best insurance on the market is because I can’t get the treatment that is the ONLY treatment that will get me well, chelation. The oligarchs are taking over ALL healthcare systems throughout the world so even the programs many believed were superior are really just like ours. Don’t go to them unless absolutely necessary.

    I have always had premium plans because they were through my employer or another employer-sponsored plan. Oftentimes these employers are paying for patient harm and they are beginning to wise up to it. And as consumers have to foot the bill they too are wising up. Medicine is going to be flatlined because technology is going to help us all figure out what it is we need to do to take care of ourselves from the comfort of our home. And that is when you will see prices fall to sustainable levels and quality improve. It’s happening.

    1. dw

      if the alternative medical folks really wanted to get Medicare or insurance to pay for their procedures, all they would need to do is test their treatments the way big pharma and company do. but they really dont want that cause that would mean getting paid less as they would also have to negotiate the price that they get. and having to pay for the testing.

Comments are closed.