Trump Adminstration Doubles Down on Efforts to Crapify the Entire Health Care System (Unless You’re Rich, of Course)

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By Lambert Strether of Corrente.

After the failure of Cassidy-Graham, the Republican Party’s fourth (!) attempt to repeal and replace ObamaCare, the Republicans appear to be doubling down and assaulting the entire heatlh care system, including not only ObamaCare, but Medicaid, and in fact all private health insurance, for which you’ve got to give them credit. I mean, at least they’re not weak[1]. I don’t pretend to be an expert on the internal dynamics of the Republican Party, but the Republicans did promise to repeal and replace ObamaCare, and if you as a voter bought into that, it’s entirely reasonable to experience righteous fury and demand they deliver. (I’ll make a brief comment on ideology at the end.) This emerging Republican strategy of crapification has three parts (first outlined in a tweetstorm by Andy Slavitt starting here):

1) Administratively, send ObamaCare into a death spiral by sabotaging it

2) Legislatively, gut Medicaid as part of the “tax refom” package in Congress

3) Through executive order, eliminate “essential health benefits” through “association health plans”

As a sidebar, it’s interesting to see that although this do-list is strategically and ideologically coherent — basically, your ability to access health care will be directly dependent on your ability to pay — it’s institutionally incoherent, a bizarre contraption screwed together out of legislation, regulations, and an Executive order. Of course, this incoherence mirrors to Rube Goldberg structure of ObamaCare itself, itself a bizarre contraption, especially when compared to the simple, rugged, and proven single payer system. (Everything Obama did with regulations and executive orders, Trump can undo, with new regulations and new executive orders. We might compare ObamaCare to a child born with no immune system, that could only have survived within the liberal bubble within which it was created; in the real world, it’s not surprising that it’s succumbing to opportunistic infections.[2])

Let’s look at each of the three parts of this Republican strategy in turn.

1. Sabotage ObamaCare

In passing, let me note that I don’t buy the neoliberal concept of equilibrium, and I especially don’t buy the notion that the ObamaCare marketplace can be “stabilized.” In fact, the ObamaCare marketplace has been continually tinkered with; it’s not like a Boeing 777 that’s aerodynamically stable, where you can take your hands off the controls and it doesn’t go into a nose-dive; rather, it’s like the F-117, which is aerodynamically unstable, and requires constant “fly-by-wire” adjustment to stay in the air at all (witness ObamaCare’s existence for eight years, and we’re still tinkering with it, even with quasi-good faith efforts like Alexander-Murray). All that said, for the first eight years of existence, ObamaCare wasn’t necessarily run by competent people — witness the launch debacle — but it was not run by malovents inimical to its goals, or even its existence as a program. Such is no longer the case, as shown by the follwing examples; the Republicans are, as it were, snipping the wires.

First, the Administration is sabotaging outreach and enrollment efforts. The Hill:

The administration has cut funding for advertising and outreach by 90 percent, raising the odds that fewer people will join the health-care exchanges during the fall enrollment period.

It has slashed funds by 41 percent for outside groups that help reach and enroll likely ObamaCare consumers..

The enrollment period has also been chopped in half, and the administration announced plans to take down the website for maintenance for hours at a time on several days during the sign-up period, two other steps likely to cut into enrollment..

All of these steps could lead fewer people to sign up for the law, which in turn might lead to higher premiums that could force others off the exchanges..

Healthy people are the most likely to drop coverage because of a lack of outreach, leaving a sicker group of enrollees that drives up costs for everyone else.

Showing the difference between the two parties: When the Democrats shut the site down, it’s because they butchered the launch due to a massive project managment #FAIL. When the Republicans shut the site down, it’s because they want to make sure people don’t enroll, sending ObamaCare into a death spiral (though, to be fair, the Democrats only want people to enroll through the marketplace, leaving tens of millions uncovered).

Second, the Administration is denying incremental, problem-solving state waivers. WaPo:

For months, officials in Republican-controlled Iowa had sought federal permission to revitalize their ailing health-insurance marketplace. Then President Trump read about the request in a newspaper story and called the federal director weighing the application.

Trump’s message in late August was clear, according to individuals who spoke on the condition of anonymity to discuss private conversations: Tell Iowa no.

Iowa is not the only red state to chafe at the administration’s unwillingness to allow more flexibility.

On Friday, Oklahoma sent a letter to Price and Treasury Secretary Steven Mnuchin saying it was withdrawing its federal waiver request because administration officials had not provided an answer “after months of development, negotiation, and near daily communication over the past six weeks.”

Minnesota applied to CMS for permission to establish a reinsurance program, which can lower premiums by giving insurers a guarantee that they will have limited financial exposure for customers with particularly high medical expenses. The agency informed Gov. Mark Dayton (D) on Sept. 22 that it would provide $323 million for the program since the lower premiums would mean savings to the federal government on subsidies to Minnesotans with ACA health plans.

But, Verma added, the federal government also would cut $369 million in funding for a separate program aimed at residents who earn between 138 percent and 200 percent of the federal poverty level and don’t qualify for the same subsidies.

Minnesota’s entire congressional delegation, Democrats and Republicans alike, issued a joint statement saying they were “disappointed that our state is facing a last-minute penalty” and “exploring possible paths forward.”

The obvious implication being that for the Administration, there is no “path forward.” And here again, it’s only the sickest people who will fight through the barriers placed in their way, again encouraging a death spiral.

Third, the Administration is creating political risks that lead insurance companies to raise rates (not that they ever needed an excuse). Marketplace:

Several states have announced rates for health insurance premiums on the Obamacare exchanges for 2018. Topping the list is Georgia, with rates that are 57 percent higher than last year, while Florida said some premiums will be 45 percent higher.

Among the reasons for these increases is the uncertainty about the future of the Affordable Care Act. President Donald Trump has vowed to repeal and replace the health care law, which was passed under his predecessor President Barack Obama. Congress had repeatedly tried and failed to deliver on President Trump’s promise.

Insurers are raising premiums in the face of repeated threats from President Trump to stop funding so-called cost-sharing reductions, payments to insurers that cover out-of-pocket costs for some low-income consumers. Trump previously referred to these payments as “bailouts” for insurance companies and threatened to stop making the payments so as to “let Obamacare implode.”

“This has been the most unstable and challenged health insurance market in my tenure as a public servant,” Dave Jones, California’s health insurance commissioner, told the Los Angeles Times earlier this week. “The degree of uncertainty and instability that the Trump administration has injected into the market this year cannot be understated.”

To set premiums, insurers estimate how many people they will cover and what that will cost. With the $7 billion in Obamacare subsidies up in the air, insurance companies struggle to do the math. They worry that without the subsidies, their policies could be too expensive and fewer people would buy them. If fewer people are expected to buy insurance, insurers will need to hike their premiums.

The bottom line is that the Administration is taking every weak point in ObamaCare’s system design and amplifying them, with the effect of making the quality of ObamaCare’s risk pool lower and lower while increasing prices, which is what a death spiral looks like.

2. Gut Medicaid

While sending the ObamaCare individual marketplace into a death spiral, the Republicans also plan to assault Medicaid through the tax reform bill[3]. From The Intercept:

proposed fiscal 2018 budget resolution Senate Republicans announced last week would lead to a $1 trillion cut to Medicaid… over the next decade, along with slashing other programs low-income individuals rely on….

The GOP has not yet publicly outlined the details of its budget proposal, but the report, from Senate Budget Committee ranking member Sen. Bernie Sanders, I-Vt., warns the cuts would attack safety net[4] programs.

On top of giving massive tax breaks to the people “who need it the least,” the proposed budget resolution would result in $1 trillion in cuts to Medicaid, which “will throw 15 million people off of the health insurance they currently have,” Sanders said Tuesday to reporters on Capitol Hill.

Republicans on Capitol Hill say it’s unfair to call it a “cut,” because it is instead a reduction in the rate of growth. That slowed growth, however, will come as the population is rapidly aging.

Worse, the bill may end up being able to pass with a simple majority. Vanity Fair:

By narrowly passing a budget resolution in the House, lawmakers are now closer to being able to use the reconciliation process to pass tax reform with a simple majority in the Senate (the Senate Budget Committee passed its own budget on Thursday and is expected to send the resolution to the floor for a vote in two weeks). The proposed G.O.P. budget …The G.O.P. budget would cut … $5 trillion in spending over the next 10 years, with a trillion of those dollars coming from the Medicaid program.

(I haven’t done the math here, but it’s worth noting today’s post that shows — follow me closely, here — that access to health care reduces reduces mortality rates.)

3. Eliminate “Essential Health Benefits” with “Association Health Plans”

To be fair, “Association Health Plans” would be implemented by the Administration through an Executive Order that has not yet been released. Kaiser Health News wrote on CNN:

A day after the latest “repeal and replace” proposal ran out of steam last week, President Donald Trump told reporters that he would “probably be signing a very major executive order” on associations that could affect “millions of people.”

What did the president mean?

Kentucky Senator Rand Paul may know the answer. Earlier that day, he ignited a new round of health policy speculation by predicting, during a cable news interview, the Trump administration would take action on a longtime Republican go-to idea: association health plans.

“If [consumers] can join large groups, get protection and less expensive insurance … it will solve a lot of problems in the individual market,” Paul said last week on the NBC show “Morning Joe.”

Under association health plans, small businesses can join associations — based on certain types of professional, trade or interest groups — that offer insurance to members. Republicans for decades have favored such arrangements, seeing them as a way for small groups to get more clout with insurers.

Paul provided few details on what he thinks the administration will do, but some health care policy experts believe that he wants to free these association plans from state regulation. Instead, they’d be considered large group plans, which would be overseen by the federal government and not subject to many of Obamacare’s rules, such as offering coverage across 10 broad “essential” categories of care, including hospitalization, prescription drugs and emergency care.

(Trump has also championed selling insurance across state lines, a bad idea.) Sarah Kliff at Vox gives further detail on the scheme:

With a repeal bill off the table, the Trump administration has drafted an executive order that could blow a huge hole in the Affordable Care Act, according to a source with direct knowledge of the plan.

The order would, in effect, exempt many association health plans, groups of small businesses that pool together to buy health insurance, from core Obamacare requirements like the coverage of certain essential health benefits. It would potentially allow individuals to join these plans too, which would put individual insurance marketplaces in serious peril by drawing younger and healthier people away from them.

A group of bakeries, for example, might form a bakers association and purchase health coverage together. The most famous examples have been farm bureaus, which allowed independent farming businesses to band together and get insurance.

Before Obamacare, national associations could pick and choose which states’ insurance rules they wanted to follow and use those rules to guide the plans they offered nationwide.

The result was often health insurance that skirted state rules and was a better deal for businesses with young and healthy employees, who are likely to prefer skimpier health plans. The former insurance regulator described the situation prior to the ACA to Kliff as being “a race to the bottom, with some associations offering lower-cost plans that covered virtually nothing.”

Obamacare changed these rules. Association health plans were treated as small businesses and were therefore required to cover all of the law’s mandated benefits.

Essential health benefits, mandating that insurers cover everything from hospital care to prescription drugs to maternity care, are central to the ACA’s insurance protections: They prevent plans from crafting their coverage to attract mostly young and healthy customers at the expense of older and sicker people, which had been one of the primary problems with the association health plan model before the law.

The Trump executive order would treat association plans as large businesses — notice how ObamaCare’s insane complexity and dependence on executive rule-making is again being used as a weapon against it — which means, for whatever crazy reasons liberal technocrats had at the time, that they would not need to cover essential benefits. The effects:

“It will destroy the small-group market,” Tim Jost, a law professor at Washington and Lee University who generally supports Obamacare, told me. “We’ll be back to where we were before the Affordable Care Act.”

So, not only would the ObamaCare death spiral be steepened, as the young and healthy sign up for skimpy and cheap association plans, the small group market would be destroyed (as sabotage destroys the “individual market”, and “tax reform” destroys Medicaid). Such a great deal!


Setting party politics and venality aside — a big ask, I know — the ideology undergirding these changes is consistent:.

Sen. Ron Johnson (R-Wis.) spoke to a group of high-school students near Milwaukee on Friday morning, and he heard from one student who asked, “Do you personally consider health care as a privilege or a right?” The far-right senator replied:

“I think it’s probably more of a privilege. Do you consider food a right? Do you consider clothing a right? Do you consider shelter a right? What we have as rights is life, liberty, and the pursuit of happiness. Past that point, we have the right to freedom.[5] Past that point everything else is a limited resource that we have to use our opportunities given to us to afford those things.

Of course, liberal Democrats think health care is a privilege, too, and they want to make sure one of their own sits in judgment of whether you get it: That’s why ObamaCare surrounds access to health care with a complex apparatus of means-testing, co-pays, deductibles, narrow networks, a system of navigators to “help” you through the complexity, and all the rest of ObamaCare’s gatekeeping administrivia. So, there’s a certain refreshing simplicity to Johnson’s view of privilege: The less money you have, the more your health care should be crapified (and, of course, vice versa). And with Medicaid gutted, the individual markets in a death spiral, the small group market nuked, and a race to the bottom with “association plans,” Johnson’s vision looks much closer to being realized. Under neoliberalism, why not?


[1] Showing crude cunning in his footwork, Trump first reached out to Schumer: “I called Chuck Schumer yesterday to see if the Dems want to do a great HealthCare Bill. ObamaCare is badly broken, big premiums. Who knows!” Liberal Democrat Schumer naturally rejected the overture, referring Trump to the [genuflects] bipartisan Alexander-Murray negotiations, a weak-tea effort to “stabilize” the indvidual market, for which there were to be hearings in September, which haven’t happened, of course. Now there’s a hill to die on!

[2] Suppose today’s Sanders bill had been rammed through passed in 2009. In 2010, every child in America would have been covered. What about the children, eh? Would the Democrats really have experienced the 2010 debacle, and their subsequent reapportionment/gerrymandering debacles? I don’t think so.

[3] In retrospect, it seems obvious that the reactionary response to Medicaid’s success would be to attempt to destroy it.

[4] As readers know, I deprecate the term “safety net.” Why should life be a tightrope in the first place?

[5] Of course, if you know the Constitution, Johnson isn’t even wrong. I’m not sure I’m comfortable with rights-based discourse generally; frankly, I think it would be more useful to enquire into the notion of freedom. It seems to me that universal concrete material benefits, especially for the working class, make us all more free, not less. But that is a topic for another time.

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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. Alfred

    Did the Wisconsin high school students, who presumably had a civics class behind them, not realize that Ron Johnson falsified the documentary evidence of the Declaration of Independence when he claimed that the “unalienable rights” are limited to just three (his putative fourth, “freedom,” being hard to distinguish from “liberty”)? The operative phrase makes clear that his three are merely examples cited from among a larger array: “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” He gives on to evince astonishing meanness in enumerating as alleged privileges the food, clothing, and shelter that are generally acknowledged to be the essential; means by which his acknowledged right to “life” is secured. It would be one thing to subject the Declaration’s statement on rights to critique. But it is quite another baldly to lie about its substance. And lying to children — is that what qualifies people for public service these days? What a disgrace.

    1. Vatch

      What a disgrace.

      No kidding! Ron Johnson qualified for public service because the Koch brothers and their allies have spent a lot of money indoctrinating Americans into believing their snake oil. So 52% of the Wisconsin voters chose Johnson over Feingold in 2016. Note that more money was donated to specifically to Feingold’s campaign than to Johnson’s, but the conservative Koch network has spent far more on general “public information” (propaganda) than than the left has been able to spend. Feingold’s campaign also suffered from the deplorable lack of coattails from the Hillary Clinton national campaign. She didn’t appear once in Wisconsin during the general election campaign.

      Johnson won’t be up for reelection until 2022.

      1. nonclassical

        …of course HC didn’t show up for Feingold…she ignored, as did (ex) DLC, entirety of left movement…

        her VP choice was final straw…(after all, “..where are they going to go..??”) “more of same”…

    2. JP

      Whether health care is a right or privilege is philosophy. A more viable argument may be that health care is like infrastructure. Like roads and bridges, healthy citizens are good for the country

      1. Jeff W

        I agree. No one argues that there is a “right” to the interstate highway system yet somehow we manage to treat it as a public good. The “right v. privilege” distinction is not just obfuscatory—it’s wrong. It doesn’t reflect how we make determinations as to what is private and what is public.

          1. Code Name D

            The “right v. privilege” distinction is not just obfuscatory—it’s wrong.
            I am not so sure. For starters, try privatizing the highway system for 20 years and see if the people don’t start talking about the “right of way” on the highway system.

            Yes, this is semantical, but semantics do mater.

            To say that “healthcare if a right” IS a philosophical statement, but it’s not without meaning. The philosophy works as the foundation which informs policy, and in turn weather policy is working or not. I also note that “health care is a right” is not an American invention, but a philosophical statement made by most if not all developed nations.

            Currently, healthcare is treated as a commodity, and this is considered to reside in the domain of the markets, an area where the government must be shut out from in order to prevent “burdensome regulations.”

            1. Jeff W

              Code Name D

              …try privatizing the highway system…and see if the people don’t start talking about the “right of way” on the highway system…

              I think that reverses the causal relationship. Some things aren’t made public goods because they’re a right. Some things are called “rights” because they’ve been made public goods.

              Calling health care a “right” definitely has meaning and it certainly makes a philosophical statement. But we provision a lot of things publicly (e.g., garbage collection, cable TV & broadband Internet service in some municipalities) and we don’t get bogged down in whether those things are “privileges” or “rights”—we do so because there are good reasons to do so and to not have those things treated as private goods, as there are with health care.

              So, whether or not health care is a right, it doesn’t make a lot of sense to get into a “dance of deadlock”—“It’s a right!” “No, it’s a privilege!” “It’s duck-hunting season!” “No, it’s rabbit-hunting season!” in figuring out whether to treat health care as a public good, especially when determinations of that sort are often made on other grounds. It’s better to say just that other advanced countries treat health care as a public good and we should, too.

              (I happen to think the “rights/privilege” distinction is pretty indefensible—it’s a conclusion masquerading as a reason and it shifts the burden to arguing that something is a “right” before we treat it as a public good. But, again, we don’t have to make that determination before we treat something as a public good.)

      2. Joel

        tldr: the Declaration is mostly BS that deserves to be ignored.

        How many people have actually read the Declaration of Independence?

        One of its still-unrealized demands was to destroy the papist threat to the north (i.e., Quebec).

        When are we finally going to live up to the ideals of the Founders [genuflects] and bomb Montreal???

        Also, per the DoI, what about “the merciless Indian Savages, whose known rule of warfare, is an undistinguished destruction of all ages, sexes and conditions?” Here we are in 2017 still dealing with DAPL protesters.

        Our country has seriously lost its way.

        Or maybe, except for the part about actually declaring independence and making a new country, it was pretty much all B.S. that the Founders [genuflects] had the sense to forget when they made the legally binding Articles of Confederation and the Constitution? The founders were politicians who, as such, engaged in a lot of scare-mongering and base-pandering and then used that as cover to make mostly good decisions.

        1. Synoia

          The founders were politicians

          No, actually: The founders were patricians

          Which means the only constituency they considered was themselves, their class.

          1. Julia Versau

            I majored in religion and philosophy in college (though I became a professional writer). I have always hungered for some “sitz im leben” with regard to the founding documents. The same analysis those GOP bastards use when they explain the Old Testament calls for stoning, polygamy, and wholesale death and destruction of perceived enemies. In biblical criticism, sitz im leben “is a German phrase roughly translating to “setting in life”. It stands for the alleged context in which a text has been created, and its function and purpose at that time.” (Wiki)

            I agree with Synoia — those guys (and they were ALL guys) — were patricians. Notice they name those three rights as “among,” not as “the only.” They didn’t need to enumerate the rights — because they already had them, via their power, money, and position.

            We need to enumerate some basics and as soon as possible. My own thinking in this regard is to include those “bottom of the pyramid” items from Maslow’s “Hierarchy of Needs.” There is no freedom without access to shelter, food, water, security, and safety. And among those safety needs — for the benefit of each individual and the society as a whole — I would include health care (including vision/dental/etc). Access requires money, either earned or gifted.

            Even patricians will regret the contagious diseases and hideous outcomes of a sick population.

            Today’s shortlist should also include utilities (for a home) and internet (corporations can’t demand online job applications in a nation without broad and free or economical access). As for transportation — given the U.S. attitude toward efficient, modern mass transportation — we need to consider it a universal need and adjust policy accordingly.

            No document should be taken as gospel for all time — including the gospels. What kind of morons would humans be to not understand this, or to only pick and choose which documents they deign to update?

            1. Yves Smith

              Except Maslow was a guy. He put sex at the bottom of his hierarchy of needs. Surveys repeatedly find that most women would rather eat ice cream than have sex. I don’t think most people would put ice cream at the bottom of the hierarchy of needs (but chocolate, now that might be a different story….).

              See the social philosopher Louis C.K. for details:


    3. Gerard Pierce

      Conservatives have been lying about inalienable rights for any number of years. The supreme court used inalienable rights to destroy the rights and privileges clause of the fourteenth amendment They did this by listing a half-dozen or so supposed inalienable rights – the right of access tp land offices and sub treasuries – the right to use the navigable waters of the US
      These were largely meaniingless and to the extent they actually meant something the were mostly infringed over the years

      The Warren Court used the due process clause of the 14th to drag the Bill of rights through a knothole — forcing rights to apply to the states.

      Because of the way he did it, it appeared for quite a while that only criminals had any rights.

      People still quote the rights and privileges clause today, with no knowledge that conservatives killed rights and privileges before the ink was completely dry on the 14th Amendment.

  2. Tomonthebeach

    That Obamacare (really Hillarycare warmed over) is flawed has never been in serious debate. It’s biggest flaw is it’s (her) top-heavy micromanagey approach to governance. It insults smart people by saying the Fed knows best even when the Fed is clueless. For not-so-smart people, ACA looks too complex to navigate – which it is.

    The incredible hatefulness expressed by the Republican mainstream towards our poor and disabled is deplorable – Clinton got them right. The wealthy do not need a tax break period – especially on the backs of the least fortunate in our society.

    What is needed is not a replacement for ACA, but a bipartisan amendment that puts a bit more discretion into the provider side of the equation, allows for necessary regional differences, and builds on lessons learned to improve efficiency and effectiveness. The public knows that – Congress clearly does not.

    1. Arduenn Schwartzman

      No, Obamacare is Romneycare warmed over. It’s more Republican than Democrat. But it has the word Obama in it, so Trump thinks it has to be erased from history.

  3. ebr

    Why do Republican think that crapifying health care is a winning electoral strategy? No, the question should be, why is crapifying health care a winning electoral strategy? That is a bleak thought, and I could be wrong, but also foolish not to consider it.

    1. Maybe it is not that the Republicans are so bad but that the Democrats are not that good (see the problems of Obamacare with narrow networks, balance billing, high deductibles)

    2. Maybe we are not living in the America that we think we are living in. Now there is a bleak thought. Sometimes it is hard though for good people who were raised by good families to be good people to understand the darkness of a soul, but we should consider it. We should treat each other as souls, not objects. At the very least we should treat each other as citizens and not objects. But everything about neoliberalism encourages us to treat each other so savagely — sending jobs off to Asia & Mexico at the very moment that automation destroys jobs at home, using electronic health records not to track disease but to track billing so that each patient is charged for every possible charge. This sort of behavior — treating each other as objects instead of as souls or citizens — corrodes the ‘we’ How easy then it is to encourage the petty jealousy of who gets Medicaid & who does not, who deserves help and who does not, when times are so hard everywhere.

    3. My criticism of universal single payer? That Congress will encourage for-profit players to grow in the health care industry. Big Pharma, or hedge funds buying up private practices to create local monopolies are bad enough. With this Congress, ‘worse’ is always an option. But it is not fair to blame ‘this Congress’ if ‘this Congress’ reflects the inner pathologies of America — our petty jealousies, bitter resentments, how consumer culture corrodes the ‘American We’ by encouraging us to think of ourselves as consumers instead of as citizens, how social media encourages divineness & echo chambers so as to promote ‘engagement’

    Maybe America just doesn’t deserve nice things.

    1. Synoia

      why is crapifying health care a winning electoral strategy?

      It wasn’t. Just ask Hillary how she enjoyed her win, or the Democrats how they increased their majority.

      1. MichaelSF

        When crapification is a bi-partisan effort (different versions/methods, but the end result is still some degree of crapification) in a two-party environment then it can’t help but be a winning electoral strategy. The crapification party (either of them) will always be a winner.

    2. Fiery Hunt

      I think part of this analysis misses the current zeitgeist:
      By bemoaning the lack of “togetherness”, some of us hear “some should go without so others may benefit.”

      Isn’t that exactly the Democrats “identity politics” that has asked so much of middle America and given them so little? Don’t both major parties play the wedge game?

      I say enough. Enough of the profit for them, peanuts for us.

      1. Lambert Strether Post author

        > some should go without so others may benefit.”

        And ObamaCare’s randomness with respect to jurisdiction, income, age, etc. reinforces this. If you’re on the bubble, you get better care with Medicaid than with the lowest level ObamaCare plan, for which you pay more.

    3. nonclassical

      …would be best for people to consider ACA was bush Medicare part D parallel…public financed subsidies for insurance company kickbacks to dems, just as Medicare part D was public financed subsidy for pharma kickbacks to repubs….

      after all, ACA is basically Romneycare = republican…it’s a matter of who kickback campaign funding subsidize…

    4. HotFlash

      Well, since you ask….

      First of all, it isn’t only Republicans. Both parties are hugely beholden to insurance funding, but the R’s can say so while the D’s can’t.

      Maybe it is not that the Republicans are so bad but that the Democrats are not that good

      Well, yeah, you are getting there.

      With regard to the ‘petty jealousy’ you mentioned, I will relate what I heard in a small town in Michigan: “I don’t want my tax dollars going to no n****r babies.” Sorry for the language, that is verbatim what I heard,and more than once.. And that. ladies and gentlemen, is what we are up against.

  4. Beans

    The ACA is a terrible bill. Since our Congress couldn’t come to terms on a repeal or replace -or anything, this is what we get. Ripping the bandaid off is a lousy way to do it, but getting rid of the ACA will ultimately be a good thing.

    1. marym

      It’s a terrible bill which nevertheless provides people with access to medical care they didn’t have before. For them, taking away access to care will not “ultimately” be a good thing. To imply that they’re worth the sacrifice is not “ultimately” a good thing for any of us, whether we’re among those who lose in the near term or not. It diminishes us all.

      1. Fiery Hunt

        Tired of being the left-out just because I’m a struggling white, male, middle aged small business owner. See “deaths of dispair” study.

        No, I can’t care about others being lucky enough to be let in to Happyville.
        Pain City has too many good people suffering in it.

        Tear it all down so we’ll be forced finally to take care of all of us.

        1. Yves Smith

          I’m no ACA fan but it unambiguously helped millions of people via Medicaid expansion.

          And if the Republicans succeed in tearing it down, you are kidding yourself that they will then go and put something better in place. You need to fight for the better first. Tearing things down is easy and gives the perps proof they can engage in even more aggressive self-serving acts.

          1. Grumpy Engineer

            And the ACA unambiguously hurt many millions of other people by driving their insurance premiums through the roof. This is particularly true among the self-employed, where the premium hikes (and deductible hikes) were brutal. I know a number of people who now spend more on their insurance premiums than they do on their house payments. It’s the single biggest expense in their lives. It didn’t used to be that way, before the ACA.

            We’ve also seen insurers pull out of markets, leaving people to face a oligopoly (or even flat-out monopoly) among the few insurers that remain.

            In terms of leftover disposable income, the Affordable Care Act made millions of people poorer. We shouldn’t forget about them and focus only on the subset of people that actually benefited.

            1. marym

              Absolutely we can’t forget people who are no better off or worse off than before the ACA. I just don’t think letting it fall apart, with the increased damages from that, represents a path forward to something better.

              We need to define and pursue a path to Medicare for All that doesn’t require or accept making things even worse in the meantime.

              I don’t totally agree with the approach Bernie Sanders is taking, but he’s right to include the fight against worse as part of the fight for better.

        2. marym

          I just don’t think tearing it down would force us to take care of all of us.

          On the contrary, it’s increasingly difficult to believe the recent close calls with repeal, and the sabotage documented in this post aren’t symptoms of our having sunk so low as a society that we can’t even find the language of taking care of all of us, let alone the will.

          Calling for tearing it all down seems counterproductive to the work of building that language and will.

          1. Lambert Strether Post author

            The difficulty is that the #SaveTheACA types will not support #MedicareForAll.

            Sanders’ plan is an olive branch and a reframing of the issue, but so far not enough have accepted it….

      2. yamahog

        “For them, taking away access to care will not “ultimately” be a good thing.”

        It is if it leads to concrete material benefits. The ACA is probably better for most than the system it replaced, but it’s still inferior (in terms of outcome vs. expense) to nearly every other system in the developed work. The ACA might be too good for us to move towards a cost-effective system, or it might make it harder to transition to something better. If we started from the initial conditions, moving towards something better would be much easier.

  5. mtnwoman

    Premiums for the self-employed are going up, such that people simply can’t afford it (esp for the dregs it offers at such a steep price). When they drop out, premiums for the remaining will go up to make up the shortfall. This will fall to large employers to take on.

    At some point, employers and the GOP voters screwed by having no insurance may finally realize that Single Payor/ Medicare for All, is the answer.

    In the meantime, millions will suffer, die, and go bankrupt. Hey, anyone find a good country to move to?

    1. WobblyTelomeres

      Single Payor/ Medicare for All, is the answer.

      Slight correction: AN answer. Outsourcing the whole kit to Canada and Belgium would be another.

    2. ArcadiaMommy

      Thank you for this comment. My family, went from $375/month in health insurance to $1600/ month in 3-4 years (can’t remember exact time frame) for our silver plan health “insurance” with a $13,000 deductible. Luckily my boys and I can use IHS and we don’t have to pay the tax penalty. My husband pays $525/month, with $12,000 deductible. Who can afford this? And we are healthy and more well off than most. I just can’t comprehend how the average person manages this. What do they do? Forgo care and hope for the best?

      1. Fiery Hunt

        Yep, that’s what we do.
        Pay cash for whatever we can (my doc is great about understanding what being uninsured means) and hope we beat the odds..

      2. Julia Versau

        Yes, they go without. I do. I can’t pay a monthly premium this high (almost like another rent payment — and for nothing but catastrophic because of the deductible). I am self-employed, and work is more sparse and the price competition is intense. I expect to die if anything goes seriously awry. I am sad about this, when I’m not totally enraged. I pay my life insurance premium ($265 a month now; I’m 63) — so my kids have money to bury my sorry ass and maybe pay off a college loan.

        1. ArcadiaMommy

          I am mostly enraged at this point. If there is a tiny positive from this trump fiasco, I believe it will be that the rampant corruption and complete disregard by this country’s leadership for the well-bring of most American citizens is laid out in the open. Maybe then we can recover.

  6. Arizona Slim

    I had one of those association health plans. It was through an astroturf organization called the National Association for the Self Employed.

    The insurance was offered by a company that is now called Health Markets. It’s so bad that the term “junk insurance” is too polite. And ISTR reading that the city of Los Angeles was suing Health Markets because of the poor quality of its plans.

    Also, do a search for the Christiansen case. It was filled by the window of a Health Markets policy holder. What the insurance didn’t cover left her destitute.

    1. Arizona Slim

      Me again. I’m back at my computer — was using my phone to post my previous comment. Here’s some backgrounder on the Christensen case:

      Key quote from the story:

      “Antony Stuart, a lawyer who lives in California, has brought more than a dozen lawsuits accusing insurance companies of misleading consumers by selling them policies that provided much less coverage than they realized.

      “Mr. Stuart recalled one case involving a man, Doug Christensen, who bought a policy from Mega Life and Health Insurance, which was the subject of numerous lawsuits and state regulatory actions. Mr. Christensen, who previously had bone cancer, was assured by the insurance agent selling the policy that he would have adequate coverage if the cancer returned. But the plan limited payments toward chemotherapy to just $1,000 a day of treatment when the actual cost was sometimes 10 times that amount. Mr. Christensen was left with nearly $500,000 in unpaid medical bills.”

      Slim’s note: Health Markets used to be known as Mega Life and Health Insurance. I had “coverage” through them too.

  7. Adam Eran

    I like the “rights v. privilege” debate. Apparently the shooter in Vegas had a right to guns, but those wounded were only treated as a matter of privilege. Did I read that in NC? I would not be surprised, it’s so shamefully true.

    1. WobblyTelomeres

      Two rules:

      Rule #1. It is always about money.
      Rule #2. If is about something other than money, see rule #1.

      If the armed started hunting billionaires, the “second amendment right” would disappear very quickly.

    2. todde

      he had a right to own guns, not a right to have guns.

      big difference – he paid for his guns…

  8. Kevin

    Even from a rights based architecture, the Senator is arguing from a morally and logically bankrupt position. There is no life without food, shelter or clothing. The same argument applies to health care, though that one is more contingent. (then again you can hack it in parts of the country without shelter) There is no right to life without the very things he named. (Note I also am not found of building ideologies on the idea of fundamental rights, but if you’re going to, don’t contradict yourself that obviously)

  9. kgw

    Let’s eliminate rich people!! No, it’s not what you think…As Michael Parenti once said, “Why are there poor people? Because there are rich people!” Let’s even the field.

    1. Synoia

      You need a mechanism to eliminate rich people. The UK left, the Labor party, did in in the early 20th Century with large death duties (Estate Taxes), with other taxes.

      1. Code Name D

        Well, there was that French Revolution thing. That’s a way. The Hamptons is not a defendable position.

  10. Pat

    While I understand the outrage under this, and I share the despair regarding the callous disregard of the political class, the coldly logical part of my brain says this really only speeds the disintegration of ACA and it’s only successful part, the expansion of medicaid.
    We have been watching the exchanges fall apart, the premium increases that bear no resemblance to supposed inflation, and insurance companies demanding ever increasing government handouts even with their well padded profits over the last few years. And no one ever faced that the Medicaid expansion funding was always shaky what with time limits and dependence on a Congress happy to cut the safety net. This just speeds the process.
    Is it political suicide? Probably. Is it sadistic? Or course. I just think the bandaids that are being eliminated only Just mean we get to the crapification of everything but private medicine for the wealthy a couple of years earlier. Because the real incremental changes needed to make the program work were almost as preferred donor unfriendly as single payer, if not more so. Between the Calvinist racists and the donor whores there was never the political will to do the right thing.
    It is instructive how little craft the Democrats used constructing their Rube Goldberg program hence leaving it vulnerable on so many fronts. But then they kept telling themselves once people had it it would be popular, a misunderstanding of what people were willing to accept similar to nominating Hillary Clinton.

    1. Disturbed Voter

      How can you call a bill “craft” … if they can’t know what is in it, until they pass it? The 2010 Congress has to be the worst on record. The Democrats deserved to lose control of Congress.

      1. Pat

        Oh there was craft, mostly PR in nature, but also in finding funding that either would disappear OR largely shifted the costs to those without most of the money. They had to meet their artificial budget constraints while shoveling money to the big insurers. ( Do not forget that they even discouraged or eliminated competition by requiring start ups to help share the costs of the losses…)

        However if you mean constructing a functioning system that made sure all Americans had health care, we do have to agree. There was no craft of even effort.

        1. Jeff

          Did Nancy Pelosi ever claim to have read the entire final ACA bill? All 2000 or so pages? If so, how much did she understand of it?

          I’m asking because this issue was raised during her oft quoted “we have to pass the bill” moment.

          Even if you’re a Democrat AND a fan of Pelosi, do you honestly believe she read the bill and understood it?

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