The Obamacare Nightmare Scenario



At a congressional hearing yesterday with Gary Cohen, the Health and Human Services official charged with managing the implementation of Obamacare, Republican legislators charged that Cohen's agency may be improperly allowing some states to run "assister" programs that pay people to help individuals sign up for the health law's coverage options. Republicans charged that HHS may not have the statutory authority to fund those programs in states running their own exchanges. That includes states like California, which plans to use a significant part of the $910 million it has received so far in federal implementation grants to pay 21,000 such assisters $58 for each person successfully enrolled in new Obamacare coverage.

To most observers, this probably looked like a strictly technical dispute over the rules governing Obamacare's implementation funding. But at the heart of the dispute is something much larger—the growing liberal concern over what might be called the Obamacare Nightmare Scenario: that too few people, who are too sick, will sign up for coverage under the law, that premiums will rise in the exchanges, and that this will reinforce public skepticism of the law as an unworkable burden whose primary effect is to cause costs to rise.

You don't need to read between the lines to see this fear creeping into the left's conversations about the law.

You can see it in former White House health adviser Ezekiel Emanuel's recent Wall Street Journal op-ed, which warned that enrollment efforts needed more attention, because there's no certainty about how many people will sign up for coverage under the law. "This uncertainty," he wrote, "could set off a negative reinforcing cycle that undermines the entire exchange system."

You can see it in Kathleen Sebelius calls to insurers, to friendly foundations, and to tax prep organizations asking them to "support" Enroll America, a nonprofit that is practically an extension of the administration—it's led by a former Obama administration health official, and its entire mission is to sign people up for the new health law.

You can see it in the anxiety over California's enrollment promotion. As The L.A. Times reported last year, "federal officials have a lot riding on the California effort," which will be "an important test" of Obamacare in the face of GOP opposition. But it all "depends on getting enough people — healthy and unhealthy, uninsured and insured — to enroll. If that doesn't happen, the state could lose billions in federal dollars and insurance premiums could soar." The piece says that California authorities expect to enroll 2 million people in private insurance through the law, and describes the challenge of getting people to enroll as "daunting."


They're right to worry. In part because, as Emanuel notes in his piece, this sort of enrollment push has never been tried at this scale. But also because a version of what they worry about—low enrollment, an unusually sick population, and spiraling costs—has happened before, in Obamacare's first, smaller-scale attempt to expand coverage to the uninsured.

For the period between when the health law was passed and when its major coverage expansion kicked in, Obamacare set up a stopgap option for hard-to-insure individuals with troubled health history—the Preexisting Condition Insurance Plan (PCIP). The initial worry with this program, one I shared, was that it would go over budget as a result of high enrollment.

That concern was half right. Somewhere between 350,000 and 400,000 people were expected to enroll in the program. Instead, just 135,000 signed up—and then only after the administration went on an aggressive enrollment push. Yet even as The New York Times reported this week, even with far lower than expected enrollment, the cost of claims in the program has "far exceeded White House estimates, exhausting most of the $5 billion" the legislation provided to fund the program.

It wasn't just that too few people signed up. It was that the people who did sign up were, on average, very sick. And thus, very expensive to cover. 

Which left states with very costly programs helping very few people: Last year Alaska said that its PCIP would cost $10 million in 2012—and cover just 50 people. New Hampshire enrolled just 80 people in its program, but spent twice its allotted federal funding. California had the highest enrollment of any state in the nation, but per-beneficiary costs came in three times higher than expected.

And what is the administration doing in response? Cutting payment rates to providers in order to hold costs down. 

This could be Obamacare's future: Not a broad middle class benefit, but an expensive program with low enrollment that mainly covers the very sick and serves as a catalyst for driving doctor reimbursements down. Granted, this is far from the only possible future for the law, and far from the only way it could go wrong. But right now, I suspect, it's the disaster scenario that many liberal supporters of the health law fear the most. 

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  1. People who pay attention to the words of politicians are Republicans or Democrats.

    People who pay attention to the actions of politicians and follow the money are libertarians.

    1. Excellent.

      “But they said….!” “Watch what they DO, honey – not what they say they’ll do.”

      1. It kills me when I see people idolizing Chairman Mao or Josef Stalin just because they said things that sounded nice. But apparently that’s what most people do: listen to words and ignore the actions.

        1. It’s all about intentions.

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    2. Not! Libertarians have their own politicians and sacred cows as much as the GOP & Dems. People who REALLY pay attention to the actions of politicians and believe in responsible, adult ACCOUNTABILITY, unlike often lawless libertarians, are GOD-FEARING INDEPENDENTS like our Founders were and wanted, for without the God of our Founders, revealed in Jesus, as they promised and warned our doom is fatal & sure.

  2. But Obamacare’s gonna “bend the cost curve”, so it’s all good.

    What, me worry?

    1. Do you know what HAS been bending the cost curve lately? High-deductible plans, which the ACA outlaws.

      1. Obamacare is bending the cost curve, just not in the direction that they implied.

        1. catcher(congress) called for the curveball, but the pitcher(market) threw a screwball, and the catcher(now the public) gets cup checked

  3. “The Obamacare Nightmare Scenario” is that ObamaCarousel doesn’t get repealed.

    1. YEah – the thought that came to me is, “The fact that it was passed is the nightmare….”

  4. Wrong alt text.
    Right alt text: “Did you hear what that stupid shit just said?”

    1. Or maybe: “Wait, you sucked his dick? I sucked his dick!

  5. If they are signing up healthy young people, they aren’t “assisters” they are CON ARTISTS. The law forces healthy young people to pay too much for insurance, so as to lower rates for older people. It is not rational for a healthy young person to buy the kind of comprehensive coverage the law demands, at the prices it will make them pay. They would be better off keeping the money and saving it or signing up for a high-deductible plan and paying the penalty. Signing them up isn’t assisting them, it is tricking them into being used as a milch cow to subsidize other people’s health care.

    1. Well, since young people were stupid enough to vote for this shit, they should be pretty easy to trick into signing up.

      1. i-stupid is a pretty strong brand.

    2. Speaking as an uninsured young man with no intention of paying for insurance until I’ve graduated with my masters, unless it’s subsidized by the university, I say bring on the nightmare. The sooner this thing burns itself to ashes the sooner we’ve a chance to implement market-based reforms (I say, all starry eyes and rose-tinted glasses). More importantly, the rage tears from the left will be delicious.

      1. Obamacare is as “market based” as any health reform could possibly get (and that is precisely whats wrong with it). Health care does not function as a traditional supply and demand market. we need a universal public healthcare system funded by a progressive tax, not a “free market” healthcare system, not Obamacare

        1. Health care does not function as a traditional supply and demand market.

          Sure it does. Health care professionals supply it and everyone demands it. Health care is a service industry just like any other. How do you think it functions?

          1. “Consumers” have no control over demand. I don’t choose to have a heart attack, or choose which hospital I get taken to. I don’t choose which medical conditions I am born with. If I think that a television set is too expensive I can buy a different one, or not buy one at all even. Health care simply does not work that way, and it will never function well as a private for profit business.

            1. Consumers could choose how they pay for healthcare (paying for hc is what this is all about, insurance it isn’t) but aren’t allowed to now and it gets worse under Obamacare. The government prescribes what has to be included in all plans and consumer choice is limited by market distorting tax policy. The hc market was never free and making it less so will not make anything better for anyone besides rent-seekers and the politicians they buy

            2. I can’t control when my roof leaks or when my oven won’t heat up either. Does roofing or appliance repair not function as traditional supply and demand markets either? We are all going to die, at some point, one way or another. Just like my car is going to shift the bed at some point, one way or another. Spare me the lefty econoidiocy please, before you expose your foolishness any further. Slaver.

            3. I don’t choose which medical conditions I am born with.

              Being born stupid isn’t a medical condition, nor is it an excuse to stay that way.

            4. “Consumers” have no control over demand.

              Nonsense on stilts.

              Consumers are bombarded with information on lifestyle choices that can improve health and prevent or delay disease onset. And even in our over regulated and restricted markets, they have choices about how to address health concerns when they do arise.

              Is there room for improvement in all aspects of this? Undoubtedly, but single payer is not something that will improve any of them.

      2. next comes single payer…

    3. What do you want to bet the “assisters” in California were 95% Spanish-speaking and went door-to-door saying things like “If you don’t sign this you can’t get amnesty” and “All your relatives can come to America for free health care if you sign this”? Stay tuned for an ACORN-like expose with HHS disavowing all knowledge of the rogues in the otherwise fine organization known as Enroll America.

  6. makes me want to start a .org informing the public of the benefits:

    the sick can get subsidized

    the healthy really don’t need to sign up until they are sick.

    1. I don’t think you’ll need to start a dot org. I think word will spread like wildfire and #Obamasnare will see the biggest, boldest stand-down on collective duties in the history of leftism.

  7. I think the true Obamacare nightmare scenario is that all of what McSuderman just wrote comes true…and when it does, our enlightened leaders implement single payer to “fix” the problems.

    1. Which is likely the plan all along.

    2. I sure hope so. That would be the best possible outcome

      1. Only not at all. Completely divorcing the costs from a service is the best way to ruin that service.

        1. Because it’s never really been about the service. It’s all about the control.

          The Oregon Medicaid study said it plain and clear – more money for no improvement in health.

          The only ‘benefit’ of government run healthcare is that the power brokers get to decide where the money flows, thereby buying themselves another set of voters.

      2. Oh look. More idiocy from the loony leftard. Next thing you know he will be praising the benefits of the NHS.

  8. Veronique de Rugy: Americans Without a Bank Account: The Next Unforseen Obamacare Implementation Problem

    Today, another implementation difficulty (or a “bummer, we didn’t think of that when we designed the law”) is surfacing. According to a new report, millions of Americans who are expected to be eligeable for tax subsidies to purchase private insurance on the new health-insurance exchanges may not be able to do so after all because they don’t have a checking account. Over at Kaiser Health News, Sarah Varney reports…

    1. Seriously? And these people aren’t already eligible for mediciad?

      Who doesn’t have a checking account?

      1. A surprising number of young people in their early 20s don’t.

        1. This is worse than the news that they don’t have driver’s licenses.

          If you don’t have a checking account, you definitely don’t have a credit card, so who is paying for your food? Mom and dad?

          1. You can deal in straight cash.

            1. The more your business is conducted on a straight cash basis, the less likely you are to want the Federal scrutiny that comes with opening a checking account, and having to explain your deposits to the FBI, the IRS, etc.

              1. Austin city council has already begun to target illegals to help them get signed up for bank accounts so they can take advantage of govt giveaways

                sanctuary city at its best…

      2. when our company went with paperless payroll, a number of the bottom-level employees freaked out. The HR department had to give pointers on how to open an account and even recommend local banks.

      3. Homeless people?

        1. Those people should be on Medicaid.

          1. Those people should be on Medicaid.

            Those people should be euthanized…..err medicaid…yeah, that’s the ticket.

            1. Medicaid is too cruel, euthanization is the more humane option.

      4. Judging by the number of check-cashing places I drive by, Hazel, a bunch of people. Poor people (you know, the ones that were supposed to be helped by this bill) often have outstanding debts, judgments against them, or other reasons for hideous credit and/or garnisheement actions against them. Hence, no bank account.

        That a Democrat office holder, and his appointees who drafted the bill, didn’t anticipate that one of his biggest constituent bases might be completely fucked by this clause is further proof of just how mindblowingly incompetent this Administration is.

        Per a commenter in one of yesterday’s threads, I cannot wait for the tell-all histories that will be written about the staggering corruption and petty, incompetent venality of this group of people.

        Provided we will be in a place where we will be allowed to read it, of course.

        1. Thank God our enemies are also tards.

        2. Those people should be on Medicaid too.

          1. Having outstanding debt or IRS liens doesn’t qualify you for Medicaid. Not everyone who is “poor” is living out of boxes in back alleys eating cat food.

          2. Hazel, I think you’re onto something. Would the defendant prefer to pay a fine, serve a few years behind bars, or be stuck on Medicaid for the rest of his life?

        3. What you fail to realize, and yet all Progressives know as a matter of faith, is that people are only poor due to bad luck, and never through any fault or behavior or choice of their own. All we need to do is provide free checking accounts, and these virtuous working-class heroes will flock to them.

          Only heartless conservatives think some “poor” people would intentionally hide assets and avoid leaving a paper trail.

        4. ” …proof of just how mindblowingly incompetent this Administration is.


          They never accounted for the poor schlubs who lack bank accounts because it has never been about the poor schlubs who lack bank accounts.

          Why would Obama do anything to reduce or eliminate a cherished voting block?

      5. Anyone who has ever bounced more than a handful of checks. Lots of people who were victims of stolen checks or identity theft.

        They are effectively banned from having a checking account because there is a private information sharing company who blacklists people it finds “guilty” of certain banking crimes (whether their fault or not) and as far as I know every bank in the country is a customer of theirs.

        1. If your checkbook is stolen the thing yo udo is inform the bank immediately and have all your checks canceled. Or preferably, you close your account entirely and transfer the money to a new one. This isn’t rocket science.

          1. That’s if you know it’s been stolen. My son-in-law had his identity stolen when he was in grade school. He didn’t find out about it until he tried to open his first bank account right after getting his first job some six years later.

            1. Nah, life is really really simple for Hazel. If you don’t have a bank account, you’re poor. If you’re poor, you qualify for Medicaid. There is literally no possibility that there exist people who have no bank account and also don’t qualify for Medicaid. None.

      6. People who have EBT cards often lack bank accounts.

        If those people also happen to earn money they certainly don’t want to put it in a bank account – that’s one of the quickest way to lose your EBT card.

  9. so people who aren’t that sick or who are healthy don’t want to blow money on medical insurance? Who woulda thunk it?

    1. I kinda did.

      Years ago (before the recent troubles) I calculated I’d get a better return with an interest bearing account than health insurance. I couldn’t get the cash instead of the coverage. (Now interest isn’t high enough, but I’d still make out better)

  10. that too few people, who are too sick, will sign up for coverage under the law, that premiums will rise in the exchanges, and that this will reinforce public skepticism of the law as an unworkable burden whose primary effect is to cause costs to rise.

    The very purpose of the act was to cause this.

  11. The thing that should be freaking people even more than the nightmare scenario listed is the following:

    To monitor compliance with these rules, the IRS and HHS are now building the largest personal information database the government has ever attempted. Known as the Federal Data Services Hub, the project is taking the IRS’s own records (for income and employment status) and centralizing them with information from Social Security (identity), Homeland Security (citizenship), Justice (criminal history), HHS (enrollment in entitlement programs and certain medical claims data) and state governments (residency).

    (via WSJ- http://tinyurl.com/prtvs5f )

    What could possibly go wrong?

    1. What could possibly go wrong?

      You Rush-listening redneck wingnut tin foil hat wearing Teapublican! What could possible make you think that the IRS can be trusted not to leak personal information for political reasons?

      1. I know. I blame Jesus.

        1. Me too. Where is that guy? He said he was coming right back!!

    2. Anyone associated with a political organization with an improper algorithmic response will have to wait an inordinately longer amount of time for anything from knee surgery to chemo. The herd must be culled.

      1. 20 years from now the life expectancy of libertarians will mysteriously decrease.

        1. And then will suddenly and abruptly rise when all that is left (heh) are the few who appear in the media telling the hoi polloi that liberty means leftism, only more so.

          Kind of like Jen Rubin, the WaPo ‘conservative.’

  12. Ezekiel Emanuel’s recent Wall Street Journal op-ed, which warned that enrollment efforts needed more attention, because there’s no certainty about how many people will sign up for coverage under the law. “This uncertainty,” he wrote, “could set off a negative reinforcing cycle that undermines the entire exchange system.”

    Translation: people who don’t know fuck-all about health insurance are going to set up risk pools that will consist almost entirely of sick people, setting up a classic underwriting death spiral where no matter how high the rates rise, the people remaining in the pool will still be insured at a huge loss.

    1. The sick people in the pools are not being insured, they’re being subsidized.
      Covering the costs of people with pre-existing conditions is not insurance, it’s welfare.

  13. “…to pay 21,000 such assisters $58 for each person successfully enrolled in new Obamacare coverage.”

    There’s no possible way this could be abused or defrauded.

    1. Don’t worry, HHS is going to hire the finest Nigerian and Russian auditing firms.

  14. I hope a large number of physicians and hospitals start to refuse all insurance and move to a cash only option with the tax code allowing writing off charity cases. The only caveat being medical tech still being heavily regulated keeping cost inflated.

    1. The two-tier system is evolving already. Check out the Surgery Center of Oklahoma.

  15. We can hope that as these 21,000 eager beavers disperse and begin their high-pressure sales calls door-to-door, Obamacare will engender the same fond sentiment as home-security firms, cable companies, and Amway.

    1. They won’t go door to door. They’ll just sit at their computers and submit made-up names, like ACORN or anonbot’s sister.

      1. I’ve heard, anonymously, that anonbot’s sister is a goer.

      2. Won’t they need taxpayer identification numbers too? I mean you’d have to fabricate a few other details, but for $60 a pop, you can have fun with it.

        1. Do you realize what you are saying? DEAD PEOPLE will be enrolled in healthcare coverage!

          1. The upside is that enrolling dead people will allow the doctor reimbursement rate to be substantially reduced.

      3. “Say, Ted, I was really impressed to hear that your sister makes $600 a day getting medical treatment through Obamacare….”

  16. If they are signing up healthy young people, they aren’t “assisters” they are CON ARTISTS. The law forces healthy young people to pay too much for insurance, so as to lower rates for older people

    Bwahhahhaaah! Feeeel it, snappers!

    I’m sorry that the more enlightened among you snappers have to suffer along with the progressotards that voted for Obama.

    So my own words of consolation are this:

    You have to make all the progressotards and their king, disappear. It’s your only hope!

    In the mean time, us geezers will keep enjoying you subsidizing our health insurance. Now, get to work!

  17. Not a broad middle class benefit, but an expensive program with low enrollment that mainly covers the very sick and serves as a catalyst for driving doctor reimbursements down.

    This is one of the advantages of not selling the public on the bill (or even your knowledge of what’s in the bill) ahead of time and just jamming it down the throat of the citizenry: Whatever the end result of Obamacare is will be proclaimed to have been the goal the entire time.

    1. Get ready for barefoot doctors, comrade.

  18. So why can’t the health care market be ‘free’ with a safety net for those that can’t afford care?

    Seems like the job/benefit mix is the problem, anything built on that is just expensive window dressing.

    1. So why can’t the health care market be ‘free’ with a safety net for those that can’t afford care?

      Because that would reduce the amount of influence Top. Men. have over the health insurance/care industries. The only goal here is to increase their influence.

  19. See, the smart thing to do would have been to impose the mandate first, and then *gradually* phase in the community rating and guarenteed issue stuff. But fortunately, progressives are too economically illiterate to bother thinking about how incentives work, so of course they fucked that part up.

    1. Who needs incentives when force will work just as well?

      1. Threat of force is the ultimate incentive.

  20. I think that libertarians often miss something very important. The Democratic party is not synonymous at all with “the left” (in fact it is a center right party). There is no mainstream left party in the United States. The left has never supported “Obamacare.” We support universal public healthcare funded by a progressive tax. Obamacare is the “free market” alternative to such a solution originally proposed by Neocon think tanks like the heritage foundation. The left was not included in the healthcare debate at all.

    1. Obamacare is the unholy compromise between the progressive left and the moderate left. Obama and most Democrats would prefer single payer to Obamacare, just like you, but they couldn’t get 60 votes for single-payer in the Senate. They really, really wanted to do something on health care, though, so they passed Obamacare.

      The funniest thing about Obamacare is that no one likes it. Republicans and most Independents hate it. Democrats would prefer single-payer. No one likes it, not even its supporters, and yet it is the law.

      1. Well you can’t blame it’s supporters: They didn’t even know what was in it!

      2. I actually agree that the resulting legislation is not really what anyone would like. I’m not sure that either Obama or most Democrats would prefer single payer. With few exceptions I don’t think that the Democrats are even moderately left (at least not on economics). For the last 30 years every administration has continued the same destructive right wing economic policies that have decimated working people.

        1. I don’t think the Democrats are even moderately left…

          Just a question, but out of interest, what are you?

          1. He’s the sort of fellow who won’t tolerate any right-wing Menshevik cunts fucking up the path toward progress…

        2. I’m not sure that either Obama or most Democrats would prefer single payer.

          Who was the puppeteer with his hand up this guy’s ass then?

        3. destructive right wing economic policies that have decimated working people.

          North Korea is Best Korea

    2. Obamacare is the “free market” alternative to such a solution originally proposed by Neocon think tanks like the heritage foundation.

      There is absolutely nothing “free market” about either Obamacare or the Neocons – especially not the Neocons.

    3. You mean a progressive tax like the one in place right now?
      Or maybe you would like to raise taxes?
      But if you raise taxes why would companies invest and hire workers, thus reducing unemployment?
      A Keynesian stimulus?
      But how are you going to pay for it?

  21. What Obama needs is the services of a supervillain who can cause all the seriously ill to die quickly.

  22. “Soylent Corp wins first assister contract in California”.

  23. “The Obamacare Nightmare Scenario”

  24. Medicaid reimbursements are already so low that most doctors view taking it as charity work. They barely break even or lose money on reimbursements. So reducing reimbursements either means doctors will stop accepting Medicaid or, for many, it is a good time to retire. We already have a huge shortage of doctors, both GPs and specialists. This brilliant plan will make it even worse. The analogy is, ‘good news, everyone gets a limo and driver to take them to work!’ The bad news is that we only have 10 limos for your entire city, get in line’. Look forward to years long waits for any elective surgery like a hip replacement. Look for your premiums to go up, for you to be reduced in work hours or you job to be eliminated to avoid the cost, to have your coverage lessened. Good times.

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  27. Here’s my nightmare scenario. With an emphasis on the reasonable sounding “Focus on Prevention”, a bunch of government bureaucrats come up with the following method of determining who gets treatment and who doesn’t:

    1. If you are sick, then you failed to follow the recommended regimen for prevention of disease. Therefore, your claim is denied due to non-compliance to health care policy.

    2. If you followed the regimen for prevention of disease, then you couldn’t possibly be sick. Therefore your claim is denied because you are obviously malingering.

    3. At any given time, the executive branch can exclude you from rules 1 or 2, and your claim gets paid with no questions asked. So if you want to take advantage of this rule, then you better cough up the goods for the party controlling the bureaucracy… (wink wink)…

    This is the dream world for the democrats.

  28. Roberts called the ACA “noncompliance” a Tax, NOT a Penalty. This creates a MASSIVE problem with the two ACA provisions: “Guaranteed Issue” (Insurance companies cannot deny coverage because of a person’s preexisting health condition) & “Community Rating” (insurers must price premiums “solely on the basis of age, smoker status, and geographic area, WITHOUT charging higher premiums to sick people or those susceptible to sickness)

    Roberts effectively has created a choice of NOT paying for coverage. By insisting it is a Tax, the retribution for refusing to purchase insurance is considered a tax ONLY if the amount stays small enough to be ineffective as a financial punishment and (Roberts) “by statute, it can never be more”.

    Rising premium subsidies to negate the difference between the cost of insurance and the Tax for not purchasing will be the only way Congress could save the ACA with “guaranteed issue” and “community rating”. I seriously doubt Congress will be able to instill this massively expensive subvention.

    It has been noted by Roberts “a person earning $35,000 a year would pay a $60 monthly tax and someone earning $100,000 would pay $200.” But it’s estimated the insurance premiums will be $400+ a month. With “guaranteed issue” & “community rating” I know I’ll be paying the Tax, not the premium.

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