Robert Reich: The Secret Republican Plan to Unravel Medicaid

Lambert: IMNSHO, capping and gutting Medicaid is the key (mis-)feature of the Republican “reform,” but the Democrat establishment is making very little noise about it, no doubt because credentialed professionals aren’t likely to be on Medicaid (except perhaps for adjuncts). Reich’s article is a welcome exception.

By Robert Reich, the nation’s 22nd Secretary of Labor and a professor at the University of California at Berkeley. Cross-posted from Alternet.

Bad enough that the Republican Senate bill would repeal much of the Affordable Care Act.

Even worse, it unravels the Medicaid Act of 1965 – which, even before Obamacare, provided health insurance to millions of poor households and elderly.

It’s done with a sleight-of-hand intended to elude not only the public but also the Congressional Budget Office.

Here’s how the Senate Republican bill does it. The bill sets a per-person cap on Medicaid spending in each state. That cap looks innocent enough because it rises every year with inflation.

But there’s a catch. Starting 8 years from now, in 2025, the Senate bill switches its measure of inflation – from how rapidly medical costs are rising, to how rapidly overall costs in the economy are rising.

Yet medical costs are rising faster than overall costs. They’ll almost surely continue to do so – as America’s elderly population grows, and as new medical devices, technologies, and drugs prolong life.

Which means that after 2025, Medicaid will cover less and less of the costs of health care for the poor and elderly.

Over time, that gap becomes huge. The nonpartisan Urban Institute estimates that just between 2025 and 2035, about $467 billion less will be spent on Medicaid than would be spent than if Medicaid funding were to keep up with the expected rise in medical costs.

So millions of Americans will lose the Medicaid coverage they would have received under the 1965 Medicaid act. Over the long term, Medicaid will unravel.

Will anyone in future years know Medicaid’s unraveling began with this Senate Republican bill ostensibly designed to repeal and replace the Affordable Care Act? Probably not. The unraveling will occur gradually.

Will future voters hold Republicans responsible? Again, unlikely. The effects of the unraveling won’t become noticeable until most current Republican senators are long past reelection.

Does anyone now know this time bomb is buried in this bill?

It doesn’t seem so. McConnell won’t even hold hearings on it.

Next week the Congressional Budget Office will publish its analysis of the bill. CBO reports on major bills like this are widely disseminated in the media. The CBO’s belated conclusion that the House’s bill to repeal and replace the Affordable Care Act would cause 23 million Americans to lose their health care prompted even Donald Trump to call it “mean, mean, mean.”

But because the CBO’s estimates of the consequences of bills are typically limited to 10 years (in this case, 2018 to 2028), the CBO’s analysis of the Senate Republican bill will dramatically underestimate how many people will be knocked off Medicaid over the long term.

Which is exactly what Mitch McConnell has planned. This way, the public won’t be tipped off to the Medicaid unraveling hidden inside the bill.

For years, Republicans have been looking for ways to undermine America’s three core social insurance programs – Medicaid, Medicare, and Social Security. The three constitute the major legacies of the Democrats, of Franklin D. Roosevelt and Lyndon Johnson. All continue to be immensely popular.

Now, McConnell and his Senate Republican colleagues think they’ve found a way to unravel Medicaid without anyone noticing.

Don’t be fooled. Spread the word.

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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. Altandmain

    The GOP doesn’t want to deal with the predictable backlash, but they are determined to wage class warfare on the rest of society.

    Robert Reich isn’t perfect, and he has gone crazy with the Russia along with impeach Trump train, but I think that he has a point here.

    1. Loblolly

      Yes, he has gone crazy with the Russian Conspiracies and he made all those whiteboard presentations about how we just all need to fall in line.

      So now he’s telling us the sky with fall in 20 years and honestly I just don’t care. Until the Democrats can talk about the present, I don’t care what they have to say. The present is where we live and the present is where we pay our mortgages.

      Whether it’s policy or strategy, the Democrats have failed. They need to get their heads out of the clouds and bring home the bacon for the working class. If they can’t or won’t then they are dead in the water, and all of Robert Reich’s beseeching falls on deaf ears.

      1. Art Eclectic

        Eh, the working class will all be living in poverty and addicted to opiods soon (those that aren’t already). But they can feel free to keep voting for Republicans because Mexicans! In the meantime, businesses will continue to find ways to import and hire labor that shows up for work and works hard.

  2. oaf

    *pay no attention to the fine print* How very innocuous! A little sleight-of-hand under the shell game table…
    Thanks for posting this article. It will be discussed.

    1. Jim Haygood

      “It’s done with a sleight-of-hand intended to elude not only the public but also the Congressional Budget Office.”

      Mitch McClownell’s simple-minded scam is quite reminiscent of the Medicare “doc fix” that began in the Clinton era:

      Established in 1997 to control the rate of increase in spending on physician services, the SGR pegged total spending among all Medicare-participating physicians to an overall budget target.

      Total physician spending often exceeded the overall budget target, triggering reimbursement rate cuts. However, lawmakers chose to push them off into the future through what were called “doc fixes,” deferring the rate cuts temporarily.

      The pending cut rose to over 21 percent before MACRA’s passage [in 2015] as a result of compounding doc fixes.

      Tightening the inflation formula in 2025 occurs the year after the Trump admin is replaced, probably by some successor to the defunct Democrat party.

      The can has been kicked — field goal! :-)

      1. allan

        I think we should all defer to noted health policy specialist Kellyanne Conway:
        “These are not cuts to Medicaid”

        White House aide Kellyanne Conway on Sunday rejected the idea that the GOP healthcare plan proposed cuts to Medicaid.

        “These are not cuts to Medicaid,” Conway said on ABC’s “This Week.”

        “This slows the rate for the future and it allows governors more flexibility with Medicaid dollars, because they’re closest to the people in need,” she said. …

        Sunday morning show word salad will always win out over facts and compounding and stuff.

  3. friendlydude

    The Republicans think they are real smart “cookies” here. What they don’t realize is that these kinds of policies (or rather, the stripping of such policies) will eventually lead to a more impoverished, and thus a more class-concious American working class, which WILL eventually topple the capitalists that bankroll the republicans (and also the ones that bankroll the democrats).

    That is not me endorsing the democrats at all, but at least the democrats had a little foresight and tried to keep capitalism alive via concessions.

    1. justanotherprogressive

      The elite Republicans and Democrats are so enamored with their ideology that they both fail to see what is happening in this country, and apparently the elections aren’t teaching them a thing.

      But apparently even History doesn’t get through that ideology. I keep hearing things like “History doesn’t repeat it self, it just rhymes”… what happened in the past doesn’t really teach us anything for today, because, yanno, what is happening now isn’t “exactly” like what happened before (so no rhyme). Yea, sure……

      You cannot have a mass of impoverished people and then take something away from them that they were given to help them survive without something very bad happening. France and Russia should have taught all of us that……but I’m sure they are like a Republican brother that I have, who thinks that the Tsar and the French king could have survived if only they had been just a little bit harsher with the rabble…..

      1. jrs

        For every French and Russian revolution there are plenty of countries where people live year after year impoverished, while the elite take whatever there is to take.

        1. justanotherprogressive

          And there are also many many civil wars…..we only hear about them after the brutality is so severe that even we can’t ignore it…..

    2. Art Eclectic

      Frankly, I don’t think the Republicans care. As Reich mentions, the worst effects won’t hit until the current crop are out of office and enjoying extremely comfortable retirements, as will the CEO’s who bankroll the party. The game is about extracting as much wealth as possible while they still can (see also: GOP current fetish with fossil fuels).

      The article posted here the other day by Gaius Publius sums it all up nicely. Make as much profit as possible while you can, then buy a protected estate somewhere to hide from the mobs.

    3. jawbone

      The meanest of the Republicans think more and more of the working poor and unemployed, disabled, seniors will just Hurry Up and Die, thus taking votes away from the Dems or even a actual leftist party or candidate.

      Republicans see the War on Drugs and more severe sentencing laws as also helping them to limit voting for the Dems or actual leftists. Get those who lean left on felonies, with required long sentences. Get enough minority men in prison, and, in most states, they cannot vote after serving their sentences. Toss out a number of minority women and it’s easier to hold Congress and state governments.

  4. Jesper

    Pharmaceutical companies might fight this – they can’t see to people without both money and withot Medicaid coverage.
    Medical costs doesn’t have to increase, medicines going off patent should make some savings but given how much money is involved I’m guessing that public good will not be prioritised.

      1. marym

        Series of tweets with links to statements from hospital and medical professional organizations and AARP opposing the bill.

        Medicaid managed care insurance companies

        This week, the heads of 10 managed care organizations — which help deliver Medicaid benefits around the country — told Senate leaders they are “united in our opposition to the Medicaid policies currently being debated by the Senate.”

        Link to paywalled WSJ post: Big Pharma Plays It Safe on Senate Health Bill

        I don’t know what the WSJ post says, but the drug industry has much to gain from the Trump administration and [bi-partisan] industry-beholden Congressional support on issues like future corporate tax breaks, continuing to disallow drug re-importation, and patent laws. Maybe they’re “keeping their powder dry.”

  5. Moneta

    Most of the best universal health care systems cost about 4K per person while in the US, your system costs something like 8k.

    So I wouldn’t worry too much about the inflation cap. In 10 years your population won’t be able to support your system as it is currently structured anyway!

    1. Disturbed Voter

      Every system has a “peak” such as “peak oil”. Though it often develops differently than the pundits suppose. In the case of peak oil, we have market and financial manipulation so that more expensive oil can be “affordable” on paper … creative accounting … that someone else will pay for, just not me. The MPC (medical pharma complex) is no different. Creative accounting results is delayed and magnified costs and distorted markets. Though free medical care would be a humane distorted market.

      This isn’t the first time the government (bipartisan) has jiggered the COLA on folks. We keep electing frauds, we keep getting defrauded. Simple as that.

      1. Massinissa

        Seems to me Americans keep electing frauds because only frauds are able to get on the ballots of the main parties.

    2. cnchal

      Politicians are the most wretched people on the planet. Self serving in the extreme. The most wretched politicians are the Republicans, so a pinnacle of wretchedness, and their grand strategy is to be in power even if it kills people and the concept seems to be, kill more Democrat voters than Republican voters and they stay in power. Brass knuckles to the people’s faces.

      Yet medical costs are rising faster than overall costs. They’ll almost surely continue to do so – as America’s elderly population grows, and as new medical devices, technologies, and drugs prolong life.

      What Reich fails to mention is that the medical system’s advertising budget is many multiples of what is “invested” in new medical devices, technologies, and drugs, and the medical system’s blatant violations of anti trust law and commercial behavior that is flat out illegal, yet not even looked at by the “authorities” are the big reasons that medical care costs climb faster than the general rate of inflation.

      Again, no economist has come forward to explain that excess profits in one area should bring new competition into that space, but somehow, in the medical zone, economics is turned on it’s head and higher profits are used to pay off the wretched politicians.

      It could backfire on them yet. It seems no one has explained to the Republicans that killing customers isn’t good for business.

      1. RepubAnon

        Republicans feel that folks making less than 7 figure salaries aren’t likely to vote for Republicans – unless they’re RepubliCult members who’ll vote for them no matter what. Given that, the Republican “let them die” strategy makes a certain kind of heartless sense: with strict voter ID laws in place, anyone requiring expensive treatments that can’t pay out-of-pocket (like, say, The Donald), would probably be forced into bankruptcy. They’d lose housing stability – and thus probably not be able to meet strict Voter ID requirements showing they were registered in the correct precinct.

        So, a win-win for the Party of Pure Evil.

        1. JTFaraday

          No, there are plenty of R voters making 5 figures. This issue is MUCH more like gay rights’ “I know someone who…” than the fetid dogsh*t from the former slave states realize. Just look at the growing gig economy, which encompasses plenty of previously upwardly mobile demographics engaged in previously upwardly mobile work.

      2. Jim Haygood

        the medical system’s blatant violations of anti trust law and commercial behavior … is flat out illegal, yet not even looked at by the “authorities”

        The curmudgeonly James Howard Kunstler has a great riff on this theme in his latest blog post:

        A colossal pool of grift exists mainly for one simple reason: the cost of everything is hidden from public view. Nobody has any idea what anything costs. Certainly not the patients, sometimes called “customers” or “consumers” — but really hostages.

        If you go into the hospital for a stent in the left descending coronary artery, nobody will tell you what it costs, starting with the doctors who have performed the procedure a thousand times. They can’t even estimate the cost (or won’t), though they could probably give you a pretty good ballpark number for the cost-and-installation of a new fuel pump on their BMW-28i.

        Charges for medical care are never discussed with the patient. Doctors especially pretend to regard such a proposition as beneath the dignity of their profession, rather like British aristocrats regarded all questions pertaining to money in the Downton Abbey scheme of things — a filthy business better left to the servants, like disposing of the table scraps.

        Of course the “servants” in the hospital scheme of things are a fantastic hierarchy of dangerously overfed clerks overwhelmed by the anomie of spending countless hours typing fictitious numbers into their work stations.

        The “authorities” have been silent partners in this squalid scheme for half a century. They like it just fine … so far.

        1. jawbone

          Are there any internet sites which publish prescription drug price increases?

          I’ve been taking Armour Thyroid, a natural drug made from desiccated pig thyroids, for several years now. Initially, I paid out of pocket (it’s not in the Medicare formulary) about $30 odd dollars for a 90 day supply. The amount barely changed for years, then about 5 years ago every new prescription was going up and has not stopped. It now goes up each refill.*

          The synthetic thyroid replacement drugs are cheaper, but, for me, leaving out the micro whatevers that the pig thyroids have makes a huge difference. The synthetic drug kept me alive, but the pig thyroid drug means I have more energy and feel more alive.

          Anyway, right now, I have no other drugs which are existentially necessary and I try to use as few as possible. But, even with Medicare Part D, some of the drugs are getting beyond riduculous in price.

          Has anyone been tracking their own drugs over the past few years?

          I have read that most of the off-patent drugs which the elderly tend to need more are the ones going up fastest in cost.

          *The long time manufacturer of Armour Thyroid was bought out by a generics manufacturer and the highest increases, iirc, have been since that buyout. Generics have been going up fairly rapidly. Nothing like the Epi pens, but still a hit to budgets.

          1. ginne nyc

            Jawbone: You should consider having the Armour formula replicated by a compounding pharmacy. I began doing this when the original manufacturer, Forest Pharma, was shut down by the feds for manufacturing violations about 5 years ago. I get the original thyroid formula in a capsule form. It costs me about $51 for 120-15 mg pills, a 4-month supply for me, including the shipping.

            The Mary Shomon website used to have a list of compounding pharmacies in different states that people rated. I live in New York, but the pharmacy I use is in Delaware, because it’s less than 1/3 the cost of those here.

            Please note that compounded capsules do not have the bad safety record like that of injections from certain compounding businesses.

    3. Alejandro

      10 years is a death sentence for those that need health care now…budgetary debates between the aloof and the sociopathic, in the neoliberal language of “affordability”, as a ruse to haze and daze the underlying class dynamics, and as decreed by the ‘demigod class’. Of course, “affordability” is not the issue for the issuer, and could be made a non-issue for the users by putting medicare/medicaid for all in the budget…#put-it-in-the-budget!

      #tax parasitic rent extraction, #tax profiteering and #tax usurious compounding interest—not because it’s needed to “fund” anything, but rather to constrain sociopathic behavior.

  6. Mike

    I at first thought the provision was simply opportunistic cutting back, but I now think it’s deliberately geared to getting the support of certain on-the-fence Senators. Such Senators might not like how the USA continues to spend money on Medicaid, but they will be happy to see cutbacks coming in outlier years.

  7. divadab

    They want to make life harder for poor people. SO they can feel superior. And pay less taxes. Win-win with this one.

  8. Doctor Duck

    A nasty, shrewd and cynical move no doubt. But does anyone really believe that in the next 10 years there will be no time when the pendulum swings, when the left holds sway and does something else, maybe even reversing this policy? A little perspective, please.

    1. Mike

      Sure there might be a time in the next 10 years etc etc. But a rollback proposed (say) 8 years from now will have 9 or 10 years of un-doing this change in its 10 year forecast, and might not be possible under Senate reconciliation rules (assuming the rules are still around, of course). I guess at that time the same trick could be pulled out – un-doing the 2025 change starting in 2033 or whatever.

      1. Moneta

        If health care inflation keeps up, in a decade it will more than double… and that’s not even accounting for underfunded pensions. How are the baby bust Gen-X, Gen-Y and indebted millenials going to prop that up?

        There will be some kind of shock before year 8. The inflation cap is annoying but the least of my worries. Red herring.

      2. Darius

        Democrats don’t do reconciliation. It’s not bipartisan and it offends their sensibilities. More important, the donors don’t want it.

    2. diptherio

      “when the left holds sway and does something else”….When’s the last time “the left” held sway over anything bigger than a march? We might get the Dems back in power, but “the left” has never, and likely will never, hold sway over anything important in this country.

      Also, read that Gilens and Page article from a year or two ago. The evidence is clear: wealthy elites set national policy, regardless of who’s in power.

      1. jrs

        The left has never held sway though they have come closer to power in the past than now. Dems might do some good with this issue if they came to power but they aren’t very trustworthy. R’s will make everything worse.

        Why the wealthy even care so much about some poor people getting healthcare (Medicaid) as it hardly threatens their vast unimaginable wealth is actually a bit of a mystery. But they sure seem to.

        1. Louis

          Why the wealthy even care so much about some poor people getting healthcare (Medicaid) as it hardly threatens their vast unimaginable wealth is actually a bit of a mystery. But they sure seem to.

          The short answer is that many in the Republican Party, especially the donor class, think that a person’s financial worth is their moral worth: i.e. if you’re poor you’re life has very little value, if not an outright a burden on society.

          1. Alejandro

            Not sure this is exclusive of the RP, but there also seems a subtle, but nevertheless detectable and noxious haughtiness in believing that their “prosperity” is merited as a result of individuated effort and not their proximity to the ‘public’ coffer…and some seem to believe that a conscious decision of frugality, somehow bestows an understanding of poverty and deprivation, and consequently bestows the ‘credibility’ and moral authority to pigeonhole and preach… recycled malthusian remnants that linger ,fester and propagate, then incubate in the subconscious, and surface as abreactions when their privilege is perceived to be threatened…

    3. Pat

      It isn’t going to take that long. Obviously anyone on Medicaid, or seeing it in their future know this is bad. But that is not the only way it fails.

      Truth be told I see nothing in this plan that is going to make the majority of their voters happy. Oh there will be minor glee that poorer people no longer have better care than they have, but high cost high deductible insurance that will still bankrupt most is not going away. Increasingly limited and useless employer provided is not going away. Most of those screaming about Obamacare are going to scream about this as well. Because it doesn’t give them what they want.

      Just as ACA was a loser so is this. I don’t know how long the political class can hold off the execution, but the current “free market” healthcare model is unsustainable. The public has already begun calling for it’s end, that is only going to grow exponentially from now on.

      1. tegnost

        …power lying in the street, who’s going to pick it up…
        That said the cynic in me thinks that medicaid is one of the more profitable health care corporate doles so it may be resisted somewhat in the smoke filled rooms, it also creates a price floor which fights the dreaded deflation that the PPACA was (imo) implemented to prevent. Also medicaid constituents make a great bunch of phama guinea pigs/consumers to pop pills the gov pays for.

        1. ambrit

          In the real, original Roman sense, Medicaid recipients are “clients.” This, after all, is what “power elites” prefer their social system to be like; as long as they stay “on top.”

    4. justanotherprogressive

      So…….which policy will be reversed?
      The loss of medicaid…
      The cost of pharmaceuticals….
      The control of medical access by insurance companies and employers……

      But let’s not stop there…
      How about the cost of education….
      What about the loss of jobs to automation?
      What about the capture of our government by big business?
      What about the excessive police militarization?
      What about our military policies in the Middle East?
      What about our dependence on Big Oil?
      What about our negative trade balance?
      What about the financial businesses that rely on all of us being in debt up to our eyeballs?
      What about our refusal to do anything serious about global warming?
      And I could go on and on and on…..

      Soooo…..when that pendulum swings as you are so sure it will, which policies will it reverse? And how will it reverse them?

    5. Massinissa

      When the Pendulum swings, it wont be the left, but the liberals, who will get into power. And they will do pretty much the same thing that the conservatives are doing.

  9. Carla

    Because I have friends with extremely low incomes who had not had health insurance for years, I learned what an incredible boon Obamacare actually was for them. Prior to O.C., it’s my understanding that Medicaid did not cover adults under 65 and without minor children. That is a lot of people. They were covered, often for the first time in decades, and without deductibles and co-pays. As one of these folks, a friend of mine had two surgeries for skin cancer on her face with follow-up plastic surgery — excellent care, her co-pays were $4 and there was no deductible. It is not hyperbole to say that Obamacare was a miracle for her, and undoubtedly, millions like her.

    Those are the millions of people the Republicrats are throwing BACK under the bus. It’s disgusting.

    I’ve been a single-payer absolutist for decades, and I detest what Obama did to healthcare as much as any right-winger possibly could (although for very different reasons). But to say or imply, as many have done on this site, that Obamacare benefited no one is just plain wrong.

    All that said, I have another friend, also with a very low income, who happens to own her home — actually own it — the mortgage has been retired. She has refused to enroll in Medicaid-expanded Obamacare because when she dies, the federal government will force the sale of her house to claw back all of what it spent on her behalf, and she wants to have an asset, or at least a dwelling, to leave to her adult child.

    1. katiebird

      But to say or imply, as many have done on this site, that Obamacare benefited no one is just plain wrong.

      Many??? I have never, ever read it here. … You should read Lambert’s posts on Pain City vs. Happyville. Most of us here are pushing to move everyone to Happyville. But no one (that I know if) is claiming it’s Pain City for everyone. In fact, it is a little offensive that you would make this claim at all.

      I am happy for your friend. But the chart in this post, Matt Bruenig: How Many People Will Obamacare and AHCA Kill? Shows that for the people who don’t get the Miracle of the ACA, things are pretty bad.

      1. tegnost

        +1, and add medicaid clawbacks as yet another reason the dismantling of medicaid may not be as close as pundits claim

      2. Lambert Strether Post author

        > But to say or imply, as many have done on this site, that Obamacare benefited no one is just plain wrong.

        One of my several series on ObamaCare was titled “ObamaCare’s Relentless Creation of Second-Class Citizens” exactly to point out that ObamaCare was unjust because its benefits were randomly and unevenly applied, not because there were no benefits. From that link:

        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.

        Don’t straw man.

        1. katiebird

          I hope this was meant for Carla. Because I was only quoting her. I totally disagreed with what she said.

          1. Anand Shah

            Yep: Lambert is adding to your points….

            Afterall, you have been credited in the main series :-)

    2. ambrit

      We have looked into Medicade here for various reasons and are appalled at the sheer “meanness” of the system. Basically, one has to be destitute to qualify. If one is not so destitute, the system takes steps to enforce destitution. It is an example of basic Calvinist theology. Ie. the Poor deserve to be poor, and treated badly, because it is Gods’ Will. So, when you read of some politico doing “Gods’ Will,” you will know them for the s—s that they are.

    3. howseth

      The medicaid expansion in California – for us personally – has been really, really good – we were without medical insurance – now we are covered – and the local administration for it ( Central California Alliance For Health) – in Santa Cruz County is managed very well – better than any commercial insurance we ever had. When the ACA started we signed up for a Blue Shield plan – which was good (to have insurance) – but not nearly as good as the local Medi-Cal we were transferred to 2 years ago – due to our income.

      As far as claw back – we do not own property and it’s just my wife and I – so it probably does nor apply in our case – but I could see that as a problem for some.

      1. howseth

        Single payer for California was proposed just recently – California as vanguard! – then quashed by the Democrats in the State House – That is really sad – because if California could somehow do Single Payer – great – and more chance for the entire USA going that way. Currently I am personally lucky with Medi-Cal – it should not be about luck. Replace ACA with a Single Payer – play hard ball with the drug companies – The Republican HACA just seems insane. Do they really believe their brand is that strong to prevent a backlash to their power?

    4. Louis

      I could be wrong about this but I believe the Medicaid estate-recovery provisions only apply to long-term care (e.g. nursing homes, assisted living, etc) coverage, not medical care, so unless she has to go into long-term care she won’t be in danger of losing her house.

      1. Splashoil

        Wrong Louis. Medicaid capitation rates apply to clawback from 55-65 yoa. That includes the monthly premiums for administering the program by private insurance risk managers (moguls).
        Clawback was instituted when it passed on a party line vote by Democrats with then VP Al Gore breaking the tie vote.

        1. ambrit

          Amen to that. I didn’t realize that the Dem turncoats included Gore.
          I’m beginning to believe that neither legacy party is worth saving if even one of the old guard remains.

  10. jackiebass

    In political terms it’s called starving the beast to destroy it. Under funding guarantees that something will fail, then it can be eliminated because it failed. The same thing is happening with public education.

    1. Moneta

      If the people want something, they’ll have to fight for it, instead of counting on Obama for change they can believe in and retreating to their flower garden when nothing changes.

      Creating a new party is probably what it takes…

      1. oh

        People keep putting their hopes on a single messiah. If they combine their efforts to form and work for a new party, it might bear fruit given time unlike the “Hope and Change”, “Feel the Bern” and similar nonsense. The Democrats have been bought and people like Reich will talk a good talk but will fail to walk that talk. Republicans are known scumbags and they’ve fooled a lot of people (including the poor and middle class) into thinking that their policies will help them.

        1. ambrit

          I dunno oh. The repubs are just the further right wing of the infamous Vidalesque Political Machine. (“America has one political party with two Right wings.”)
          The lack of “on the ground” organization seems to be key here. Lambert often bemoans the fact that the Democrat Party hasn’t done any serious voting enrollment drives or other practical “outreach” programs. Perhaps the reason for that is that the Elite Core of the Democrat Party Apparat are afraid of the “leveling” and “humanizing” effects such an influx of “ordinary” people would have on the Party. All the Republicans have to do is demonstrate to a small cadre of “business” functionaries the “positive” effects of the Republican Parties’ policies on them, a small but cohesive population, to gain a source of power greater than that populations’ numbers alone would suggest.
          Finally, we are but Human. One of our failings is a propensity to desire “Leaders” and “Experts” to relieve us of our anxieties. Animals in the wild depend on “herds” and similar structures to survive as species. Humans are but one step above the animals. (Even that formulation can be argued against.)

          1. Heather

            Very Interesting. I was just thinking about this last night. When i was a kid growing up in Hawai’i in the late 60s and early 70s as a teenager, I volunteered on a Dem campaign for govenor. We used to walk precincts and hand out leaflets, knocking on peoples doors and actually TALKING to them. And, boy, did I learn a lot that way. I was sent to precincts where actual poor people lived and it was a very eye-opening experience for me. And people really wanted to share their lives and let you know how hard things were for them and to hold a conversation (talk story) with you. I was thinking, when was the last time anyone came to my door to talk about a candidate and to listen to me? And when was the last time anyone from one of the two parties listened to you? No wonder they are ALL so out of touch!

            1. ambrit

              Good point. The last time a political candidate came to our door, he was a right leaning independent. He was just recently elected mayor of our mini-metropolis.

          2. Left in Wisconsin

            The Dems are the party of the meritocracy. What a meritocracy needs above all is a super stable environment. Otherwise it becomes to difficult to determine the criteria determining who leads (who wins). That is why they gravitate to the public and NGO sectors – more rule-based stability.

            A shrinking pie isn’t great for meritocrats – reduced opportunity and all – but it is way, way better than upending the existing order. Which is why (existing) Dems will never, ever propose that. Also, meritocrats are not eager for more competition for limited slots “running the show.” So you will never find Dems going out of their way to locate new bases of political energy, esp political energy that is not enamored of the status quo.

          3. Bobby Gladd

            “the Elite Core of the Democrat Party Apparat are afraid of the “leveling” and “humanizing” effects such an influx of “ordinary” people would have on the Party.”

            In 2008 I volunteered with the Democrats (for Obama, notwithstanding my being an independent at the time). The itinerant Party campaign mgmt people were insufferable, they made it clear to us proles that they had all the answers. We were to just shut up and do as told.

            I quit wasting my time. But, — to Heather’s point — I did subsequently become a precinct captain for Obama, and did a ton of calling and door-knocking. That was definitely worth my time, talking to regular people.

            1. ambrit

              Good for you to have taken the time and expended the effort to do actual politicking!
              Now, if only Obama had lived up to his hype.

    2. tegnost

      The difference is that public education is being privatized but that has not yet been completed at the k-12 level, though student loans have effectively privatized higher ed, while health care is mostly private already, and medicaid is socialism for health insurance, medical deice, and pharma corps.

  11. Stephen Douglas

    Articles like these? They have this theme: those nefarious Republicans, they are secretly screwing people. In secret. It’s all such a big secret. And no one–but the writer, the blog runners, and now, of course, us–knows that the real reason they are doing all of this is to impoverish and kill our grandmas.

    Well, the Republicans, some of them, might just be that stupid. Some of the utterly clueless statements by some prominent Republicans about what they think that they are accomplishing by repealing (and replacing) Obamacare do seem to indicate they think that they are bringing “choice” to Grandma.

    It could mean they know exactly what they are doing, know it’s evil (i.e., it will kill grandma), and are doing it anyway. In other words, they truly are evil.

    Or it could mean they are stupid. They think that the only thing that Americans care about is “choice.” In other words, the only thing we care about is to be able to have a “competitive” market in which to spend our non-existent dollars on “our” medical care.

    Reich seems to forget (and it’s easy for him to forget, obviously, since he also believes that Russians run Trump, that conservative speakers at my ex-alma mater and his current University hired antifa thugs to break up their own speeches, and other looney nonsense) that Trump was elected to make things better for Americans, not substantially worse.

    So do many others who write articles that appear here occassionally (Bill Black, Nomi Prins, et al). They write merrily along “proving” that all Trump has done or is doing is hiring a bunch of rich guys that are just there to “implement” their plans to screw everyone–except those with a lot of money–royally.

    That’s not what Trump promised. That’s not the basis of his popularity. His continued popularity. The continued popularity of Republican leadership.

    That’s not the result that anyone will vote for in the future. If that is the result that Republicans bring to the United States, Grandma will die. If Grandma dies, Trump loses his base, the Republicans lose their base.

    You all seem to be believing the same thing that corporate Dems believe: voters have no alternative. If we all IDems, Repubs, Trump) make it worse? Who ya gonna vote for? There’s nobody but us to vote for. Ha ha ha ha ha.

    I think you all are wrong. And Reich especially. He, and every writer who writes with this kind of overview (secretly being screwed by right-wingers) would do well to just write about what doing this or doing that will result in. How it will affect Grandma.

    Drop the moralistic bellowing and the hurt-looking outrage (Elizabeth Warren, are you listening?).

    Be cold, be succinct. Be clear. And relate it to this: If repeal and replace does not make things better for Americans, the Republicans will be looked upon as utter failures by a large majority of Americans, and this will be reflected immediately in the politics of the United States.

    I’ve said it before, and I’ll say it again: the jig is up. The time for fake promises that do not produce results that end up making the medical nightmare BETTER for people was over about 4 years into Obama’s reign. Neither Trump nor Republicans in office at this current fragile moment im time have leeway to NOT make it better.

  12. FidderHill

    This “new party” mantra to save us all from the existing two major parties is deluded thinking. I’ve noted before how effectively the two parties have convinced a majority of voters that we’re “wasting” our vote if we vote third party and how difficult they’ve made it for a genuinely new party to even get ballot status.

    But after the last deluded call for a “new party,” I went through the history of political party development in the US since 1800. I plan to construct a detailed analysis of the evolution, party-by-party, and post that later for those geeky enough to be interested.

    But my cursory examination proves what I have long suspected: that the US has been dominated since the beginning by two parties. And that every “new” party which developed was in fact a major splinter group from one of the two existing parties, a faction which broke away and formed a new coalition, sometimes under a new name, sometimes not.

    What was left of the original party then withered and the new coalition superseded it. Sort of the way, you might say, Bernie Sanders laid the foundation through his primary campaign for a major splinter group of Democrats to form a “new” party that would supersede our current, very corrupt Democratic party.

    1. edr

      And each of those NEW parties that replaced an old party initially DID produce the results and carry through the goals of new and better policies that benefited the population as a whole. Therefore, new parties have a proven record of success.

      A major registration drive for a new party with a new platform would end concerns with “throwing away your vote.”

      I’d love to see a new party that backed a truly centrist platform, rather then Clintonite fake centrist:

      1- Passing a constitutional Amendment stating that corporations are not people and only natural born persons have constitutional rights and guarantees, and only citizens can contribute to politicians and political parties, Pacs, etc.
      2- Re-establishing Glass-Steagall and breaking up the big banks by separating investment banks from commercial banks, from insurance companies, and maintaining those services separate.
      3- Enforcing anti-trust laws to prevent and end the monopolistic mega mergers and acquisitions that are destroying small businesses throughout the nation and “reducing people from owners to clerks.”
      4- Refunding the Social Security Trust Fund – and disallowing those moneys from being diverted to other areas.
      5- Prohibiting all forms of Private-Public partnerships, especially in the military and the prison system.
      6- Ending the wars

      Imagining something that could work is the easy part. Organizing it is the difficult work.

      1. Moneta

        Here in Canada, new parties don’t take over but they do force the dominant ones to change.

        I find it baffling how many people think the Dems will change without an outside shock!

    2. Lambert Strether Post author

      > I plan to construct a detailed analysis of the evolution, party-by-party, and post that later for those geeky enough to be interested.

      That will be interesting to see!

      That said, I find “let’s start a new party” puzzling, because the idea seems to be that the Democrats can simply be bypassed. But they need to be assaulted, no matter what! It’s like the Goths said to themselves: “Nah, we’re not sacking Rome. We’re going to build a new one!”

      The hidden story of the “ghost candidate” is that the Democrats still had that ballot line. That is an asset to be seized, like a lot of other Democrat assets (since they are written into statute in all sorts of ways).

    3. Vatch

      I agree that the call for a new party to save us is deluded thinking. There already are numerous political parties in the U.S., and most of them are even less effective than the Greens. Here’s a possible starting place for research on U.S. political parties:

      The Republicans and the Democrats are colossi compared to all of the other parties combined. Anyone who is interested in change that takes less than a decade to achieve must focus on either the Democrats or the Republicans in the 2018 primaries.

  13. Kris Alman

    To top it off, the Hyde Amendment is built into the bill. No need to reauthorize yearly to eliminate coverage for abortions–other than those resulting from rape or incest or that saving the life of the mother. (Never mind that economic austerity kills.)

    Also here’s the kind of data that will be collected for the Transformed Medicaid Statistical Information System (T-MSIS) of the “Medicaid Flexibility Program.”

    (I) survey data, such as the data from Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys;
    (II) birth certificate data; and
    (III) clinical patient data for quality measurements which may not be present in a claim, such as laboratory data, body mass index, and blood pressure

    Because, you know, poor Americans must prove they are accountable and taking personal responsibility for their health. And it’s economic stimulus. Harvard, Stanford and MIT grads with their big data analytics degrees will be gainfully employed!

  14. Dandelion

    The Hyde Amendment is codified into the ACA as well. At the time it passed, there were a number of provisions that sold out women: the separate policy enrollment necessary for abortion coverage being the most egregious, as well as the codification of Hyde. Progressives insisted women had to “take one for the team” and all would be fixed later.

  15. jawbone

    Medicaid is being attacked financially pretty openly, I think. And, its enrollee numbers will be winnowed down, due to the cuts to funding.

    What I’m not seeing is much attention being paid to the effects on Medicare. So far I’ve seen articles about how cutting the taxes on wealthiest Medicare recipients will result in more “lock box” funds being spent on costs, especially as the huge numbers of Baby Boomers age into Medicare.

    The Repubs have been working to destroy Social Security ever since it was seen by FDR as a means to adjust wealth in this nation and protect the elderly. Health care was planned to be put in place after SS got established, but that was put off after WWII and then FDR’s death.

    Now, the Repubs have control of Congress and the presidency and will try to do everything in their current power to destroy or lay the groundwork to destroy both SocSec AND Medicare. By cutting its future funding, they are on their way to “proving” Medicare “unworkable.” They will do whatever they can to cut SocSec taxes to prove SS in “unworkable.” Their “fixes” will be the death of these programs.

    Unless voters figure things out and support more leftist politicians. May Bernie stay healthy and able to build up the number of leftist candidates and voters.

    We need investigative reporting that Follows the Money. Written so that it is clear what the Repubs are doing.

    1. Bobby Gladd

      The Kellyanne Conway Medicaid solution today: “Get a job with benefits.”

      And, yeah, you’re right. The Paul Ayn Ryan et al wet dream is to convert all “entitlement” programs into spend-down-to-penury for (nil) means-tested eligibility.

  16. Ignacio

    Coward legislation, secretive treaties. They know that what they do hurts people, and they don’t care about it. This is the message that has to be passed and repeated. Republicans just want to hurt people to feed their greed.

    The initiative must be killed before it is born.

  17. Scott

    I have not seen any prominent voices articulate what is learned from the study of Modern Monetary Theory, where the word Modern is not the lie word “Modernization”.
    “Reform” means regressive.
    It is hard to fathom why Finance banking is intent on killing the golden goose from where their interest flows. Greece & Puerto Rico are not jokes.
    Unpayable debt is what keeps the US from being uncompetitive. All the gains made by The Great Generation that flowed from free GI Bill Education are being wiped out, and the core strength of a socialist democratic nation destroyed with debt.
    Debt is not some sort of discretionary choice when it comes to education and a place to live. Bankers glee at chasing government guarantees of no forgiveness while MBAs are taught to never pay labor and the end result is stagnation.
    Healthcare is same as Defense as evidenced by the CDC, and the VA health system. Banks want to create debt wherever they see any spending, and it gets to be simply too much.

  18. kw

    What if health care costs don’t increase as fast as inflation in 2025? Seems this analysis assumes things stay at the same ridiculous trajectory.

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