Obamacare

Obamacare Is Stuck in a Feedback Loop of Bad Policy and Bad Politics

The debate over whether the health law should even exist has never been resolved, making policy fixes all but impossible.

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Whitehouse.gov

Obamacare has both a policy problem and a political problem, and the two problems are now caught in a predictable feedback loop which ensures that the law not only continues to break down, but that it will be difficult or impossible to fix.

The health law's policy problem is plain for all to see: Premiums for individual insurance sold through the law's exchanges are rising rapidly, enrollment is far lower than initially expected, and insurers are dropping out of the system. These effects are directly linked. States have begun to approve insurer requests for premium hikes, and in places such as Kentucky, Georgia, Virginia, and Mississippi, insurers are receiving permission for double-digit increases. As The Wall Street Journal reported last week, regulators fear that if they do not approve these rates, insurers will simply drop out of the exchange business entirely. In Tennessee, two of the three insurers in the exchanges were allowed to refile their rate requests, according to the state's insurance commissioner, out of concern that otherwise they would exit the market entirely. These hikes are not arbitrary or over the top. The state's actuaries have said they are justified; they reflect the cost of covering claims to beneficiaries.

Several major insurers, of course, have already substantially scaled back their participation in the exchanges, leading to a situation in which a third of counties in the U.S. will have just one insurance provider operating through the exchange, a significant increase from last year. The Obama administration released a rather defensive-seeming analysis last week finding that premiums wouldn't rise much for most people buying through the exchanges because the subsidies will rise with the price of coverage, but that simply means that taxpayers will pick up the rising cost of coverage. And that provides only temporary relief. The provision that protects health law beneficiaries from hikes expires starting in 2019. In addition, the administration seems to be backing away from the promise that President Obama made repeatedly when advertising the law that "if you like your doctor, you can keep your doctor," having removed language to that effect from the federally run health exchange portal.

In any case, experts—even some who generally favor the law and its goals—are starting to question the stability of the exchanges. The current problems facing the exchanges "threaten the future stability of these markets and will require serious policy solutions to address," Caroline Pearson, a senior vice president at health consulting firm Avalere, told Stat News. Uwe Reinhardt, a prominent health economist at Princeton University, warned this week that the exchanges could implode. "We all know about the death spiral that actuaries worry about," he said in a recent interview with Vox, "and I think what you're seeing now is a mild version of that. These things accelerate, as premiums keep rising."

That is the essence of Obamacare's policy problem (or, one could argue, problems): It is not working as promised or intended, and, even if it does not totally melt down, it is not, on its current trajectory, likely to improve.

Obamacare's political problem, meanwhile, is related to its policy problem: There is nothing close to consensus on how to fix the law's problems, or whether to even try.

Thus far, the political dynamic around the law has been almost entirely binary, with Republicans pushing for repeal and Democrats defending its coverage gains. Some tweaks have been made at the margins, mostly small changes that further destabilize the law's policy scheme in order to bolster it politically (the Obama administration's decision to grandfather in many plans in order to keep its promise that those who like their plans can keep their plans, for example). Health policy wonks on the right and left have batted about various reform schemes, of course, offering various plans to fix, expand, and totally upend the law—sometimes only to put many of its primary elements right back in place.

But at the national political level, there has been little meaningful discussion of how to modify the law; instead, the debate has focused on the question of whether or not the law should even exist. More than six years after Obamacare became law, there is still no consensus on this question. In part that's because, even though the law has survived legal challenges and technical meltdowns, covering millions in the process, it has also suffered a persistent string of failures and frustrations, leaving many to continue questioning whether or not it was ever really a good idea, long after its passage. More adults continue to hold an unfavorable view of the law than a favorable one.

Because this existential question has not yet been resolved, the political dynamic has remained unchanged. And what that means is that fixes or reforms of any kind lack the requisite political support to pass. In recent months, Democrats have settled on support for a "public option"—a government run health insurance plan that would compete alongside private insurers in the exchanges. President Obama endorsed the idea in an article for the Journal of the American Medical Association, while Clinton came out in favor of it too, though neither has devoted significant energy to selling the idea publicly. After years of promises, meanwhile, Republicans finally released a pseudo-plan to replace the law, a Frankenstein-sketch of reanimated ideas, many of which are already included in Obamacare in some other form. Needless to say, the current Republican standard-bearer, Donald Trump, has not exactly devoted energy to making the case for this plan.

In my view, the policy cases for both reforms are weak at best: Obamacare already included a substitute for the public option in the form of a series of government-backed nonprofit co-ops, the majority of which have already failed. The Republican plan is just reheated GOP health policy leftovers, designed in a way that might be even worse than Obamacare in some respects.

But in some sense, the policy cases, for or against, are beside the point. Because in any political environment that requires bipartisan support—the likely case, unless one party manages to secure both chambers of Congress and the presidency in the upcoming election—it is almost impossible to imagine any consensus.

Democrats and supporters of the law will, of course, say that this is entirely the fault of intransigent Republicans for refusing to rally behind a law that is providing coverage to millions. But that's a difficult case to make given the consistent weakness of public support for the law, and even more difficult as it looks to be unraveling before our eyes. It is essentially an argument that Republicans must now rally around a law that they opposed on the grounds that it would fail, and that is now failing, by empowering the same people who promised that the law would not fail to fix it.

Even if you accept the argument that the law could be fixed if only Republicans would come around, what it amounts to is an admission of a design flaw built into the law's joint policy-political scheme: Democrats passed a major law with multiple potential points of failure that could only be addressed with bipartisan support—but they passed it over the strenuous unified objections of the other party.

Republicans are not blameless either. As a party and political institution, the GOP wasted years both before and after the law essentially declining to make a positive case for any kind of health policy at all, leaving open the door for Democrats to pass the reform that they did. The GOP's total opposition to the law, combined with a lack of clearly articulated alternatives, has rendered the party less trustworthy on the issue.

And so the fate of the law, and of national health care policy more broadly, is stuck at an impasse: If the law's exchanges continue on their current wobbly trajectory, they will continue to break down, perhaps collapsing completely or perhaps not, but in any case functioning less and less well over time. But barring an unlikely electoral majority, the political dynamic surrounding the law is likely to block any fix or wholesale do-over. In the meantime, the ongoing policy failures will continue to harden the political dynamic, making the nation's health policy problems even harder to address. Obamacare is bad policy magnified by bad politics, and for the foreseeable future, its problems are likely to grow worse on both fronts.

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  1. “All quag can be upgraded!” prattled the shiftless quixotic.

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    2. You should probably stay away from the Philipenes.

      1. He’ll have to boycott the Scrabble world championships the next time they are held there.

      2. Philipenes?

        Is this a reference to some kinda lady-boy? Belong in the next post up?

  2. you mean government is stuck in a feedback loop.

    Detroit, Venezuela, Greece. People never learn and just double down on the derp

    1. The only reasons it didn’t work:

      1. Republicans

      2. White people

      3. We didn’t do what we were doing enough because 1 and 2.

  3. Obamacare is bad policy magnified by bad politics

    If you have never looked at *the actual legislation*, I encourage you to do it.

  4. This was not an uplifting post. However, as usual I have a solution: expand free Medicare for anyone who needs it. Boom, problem solved.

    1. Free complete cradle-to-grave medical care for all citizens.

      But that is *the only* government benefit.

      1. Not for all citizens dingus, only those who need it should receive free Medicare. The wealthy still have to buy their own healthcare as long as it meets federal standards.

        “But how will we pay for it, Big Juggs?”

        Thanks for asking, beefcake. We will pay for it the same way we will pay for free college, and the same way we will pay off your college loans: levy taxes on the wealthy so that they can finally pay their fair share.

        1. I never knew legislation could be helpful AND sexy.

    2. Julia approves!

  5. BUT WURS TEH DEATH SPIRUL PEANUTS

    the administration seems to be backing away from the promise that President Obama made repeatedly when advertising the law that “if you like your doctor, you can keep your doctor,” having removed language to that effect from the federally run health exchange portal.

    Isn’t that just typical: we broke this thing and can’t fix it, so we’re going to scrub our fingerprints off it. Absolutely pathetic.

    1. it was a lie, never true to begin with. but it’s a lie that helped get it passed, so it’s all good in the prog mind.

      1. It was widely know that it was a lie even as it was first uttered, including by the person who uttered it.

    2. That cost curve is also bending down, right?

      1. Under the sheer weight of those costs.

      2. to be fair he only ever said he’d bend the cost curve, he didn’t give a direction so this promise came true.

    3. See, even if premiums level out or improve (though likely getting no better than those the system sought to replace), all the ACA has done is bake in major problems indefinitely, or at least until we get another raft of deregulations. So, congratulations to all of the president’s boosters, you’ve created another ICC which, in the fullness of time, will be unceremoniously dumped in the scrap heap of bad policies.

    4. But they really thought it would work this time. How much harder than Harvard could planning an economy be? Anyhow, who the fuck thinks that something is so important that the govt should do it? People who don’t live in this reality? That’s like bringing your brick bag swimming

      1. Democrats run no risk for implementing expensive technocratic projects. They’re opaque, incomprehensibly expensive programs with so many moving parts and clustered interests that it’s impossible to summarize their operations simply or persuasively to most voters. They almost certainly notice and loathe the premium and deductible hikes, the lost plans, the provider curtailment, etc., but it’s a labyrinthine process tracing it back to the relatively archaic mechanics undergirding the ACA. Especially when the originators of the mess have a handy excuse: it’s the fault of intransigent Republicans for failing to seriously back this monumental undertaking, the fault of insurers who want higher profits than they get through the exchanges, the fault of Paul Ryan for quashing the risk corridor bailouts transfers, the fault of affluent customers who want cadillac policies rather than paying Their Fair Share into exchange plans.

        So this thing inevitably collapses: so what? Democrats get to force the issue on single payer, and won’t get called out by taxpayers or voters. Their complicit media lapdogs certainly won’t draw any of the obvious parallels. And meanwhile Congressional Republicans get their teeth knocked in on the subject despite working to restrain the abomination in the first place. Win fucking win for the left.

        1. As a party and political institution, the GOP wasted years both before and after the law essentially declining to make a positive case for any kind of toe-sock reform at all, leaving open the door for Democrats to pass the reform that they did. The GOP’s total opposition to the law, combined with a lack of clearly articulated alternatives, has rendered the party less trustworthy on the issue. – Peter Suderman in ten years

          1. Yeah I see people trying to play this game on Facebook too. It is the GOP’s fault for letting the Democrats ram this through. It’s bullshit. It was bullshit then and it is bullshit now. Anyone trying to play that game is just a Democrat apologist.

            1. Like a drunk bipolar woman after getting into a car accident, shrieking ‘why didn’t you stop me, you know I was drunk, you should’ve stopped me’ when you know that the moment you would try to stop her she’d call the police and get you arrested for domestic violence.

  6. OT

    My buddy needs some gun advice. Anyone around with an opinion. He wants an Elk rifle. He’s getting it in a .308. Here is his question:

    I can get the Kimber 84M Hunter for $850 or the Savage 16 Lightweight Hunter for $585 after a $75 rebate. Is the Kimber worth an extra $265?
    Thoughts?

    Any help from our resident “gun nuts” would be greatly appreciated.

    1. Like most gun opinions, mine lacks actual data.

      Get a Remington if you can afford it.

      Savage otherwise. Elk are big targets. It is a bolt action and not a complicated piece of machinery.

      1. Scope makes a bigger difference than savage vs Kimber.

        1. And the scope will cost 2x the price of the rifle.

    2. What ranges does he plan on using it at, and how far will he be walking? The Kimber is slightly lighter, and has a better action. The Kimber will also, most likely, be slightly more accurate, though not by enough to matter for most practical hunting ranges.

      I’m a sucker for Mauser actions on my bolt rifles and I’d pay the extra $265 for that alone, but he may not care that much. If he doesn’t have much of a preference and doesn’t mind the extra weight, I’d tell him to go with the Savage.

    3. I’d probably spring for the Kimber. This is a major piece of capital equipment he will have for the rest of his life. Might as well get the best you can afford.

      1. To be fair, I think the rifle is probably the least expensive part of an elk hunt.

        What about a Remington 700? I think there is a lightweight version with a 5R barrel that would call to me if I were hunting elk. I could be wrong about the specific configurations they offer.

        1. Lightest Remington I could find was 6.5 pounds, a full pound heavier than the Kimber.

        2. I like 700s. My elk gun is a Rem 700 in.300 Win Mag. Very nice gun. Bolt is slick as greased glass, and with the sort of accurizing you should do to any factory gun (crowned barrel, cleaned up/lightened trigger) it shoots sub-MOA groups.

          1. One other accurizing recommendation: get the barrel lapped.

            1. These euphemisms….

  7. Ah remember the cheerleading when ACA passed?

    And the crowing when Roberts let it stand?

    good time, good times.

    1. Ah remember the cheerleading when ACA passed?

      Watching that crap get rammed through congress was one of the most nauseating experiences of my life.

      1. People literally cried. Out of joy. Over a law getting passed.

        1. You clearly don’t remember the dark days of the pre-Obama era. Poor people were dying in the streets from lack of Obamacare. You could walk two blocks without seeing some just collapse BOOM! Dead! Not enough Obamacare. But lo! Barack H. Christ reached unto the heavens and bestowed Obamacare upon us all.

        2. If we had a leader with real balls in charge, each vote for the ACA would be the basis for treason charges. Then there would be some real crying from the democrats.

      2. I’m still kind of wondering what the fuck happened there.

        1. A completely euphoric and deranged optimism following the end of the Bush Presidency and the Ascendancy of Obama. With Bush gone, cries of ‘the Republican party is dead’, the Democrats basically being in charge of everything, and their new ‘charismatic’ Golden Boy in power they really thought it was the beginning of a one-party rule where they’d be able to fundamentally change American politics and culture and bring themselves closer to their beloved utopia. Of course, in reality they did change Americans politics and culture, but not for the better.

          1. I mean more the specific procedural trickery used to get the thing through the Senate.

            1. The forced a non-spending bill through the loophole in Senate filibuster rules for spending bills.

    2. Biden thought it was a big f***ing deal.

    3. You mean insurance companies aren’t clawing over each other, dropping prices to complete for the business of people with pre-existing conditions who must be served, no questions asked?

      Who could have seen that coming?

      See? Free markets just don’t work.

      1. Yep. People should have known from the beginning that Obamacare was too free market to work.

        The sad thing is the new Sanderite wing of the Democratic Party will be making this argument in the future if they’re not already.

        1. They were making that argument even before it was passed. They’re the ones who’ve always wanted universal health care.

          1. Now it’s the French model that’s all the rage among them. They love to talk about how great French healthcare is and how we should emulate them. Force us all to pay for free homeopathy for every halfwit in the country, let people go shopping for expensive brand-name drugs instead of pharmaceuticals on the taxpayer’s credit card. That’s the life. The things we choose to do together.

            Just listening to all the prattle makes me consider just saying to hell with it and resolving to work a government job the rest of my life. Hey, if it’s inevitable, I may as well enjoy the taxpayer-provided weekly massages myself, right?

        2. We really need some kind of law to protect sanderistas from their own stupidity.

          1. We really just need to stop passing the law they want, and they’ll die off on their own.

    4. I wonder which unconstitutional political decision Roberts will insist we suffer the consequences of next…

  8. The “debate” over whether or not Obamacare should exist is merely an academic one, it’s a government program now and you’d have better luck trying to kill Jason Vorhees with Freddy Krueger’s corpse than trying to kill a government program.

    While I’m not generally a conspiracy theorist, it doesn’t take much of an imagination to suspect that Obamacare was never intended to work as advertised – the specifics of the program didn’t matter a damn bit, as long as some sort of government program established the general principle that it was right and good and proper that government run the healthcare industry, well, we could haggle over the details later. It’s that one-way ratchet of when government intervention fucks something up, well obviously we need even more government intervention to fix it. Government doesn’t give a shit if they’re driving the car off a cliff, all that matters is that they’re the ones driving.

    1. Obamacare is fine, we just need different Top. Men. /squishy moderate

    2. Agree with this. And there will come a point where Obamacare – as it stands – is even more untenable. And there will be cries for reform. The Republicans, with the Democrats bi-partisan help, will be forced to pass “something” to “fix” the problem(s). And so it goes…

    3. There’s a much more reasonable explanation: being a Democratic administration and this being a bold, highly visible undertaking, whether it succeeds or fails is immaterial; the left gets something they want out of either outcome, and they’ll never be held accountable for it. Economic chaos favors lefty populism, so the left sows chaos wherever possible.

      1. Being rehired to fix problems you caused. It’s good work if you can get it.

      2. So what you’re saying is that they managed to pull off a Xanatos Gambit

    4. While I’m not generally a conspiracy theorist, it doesn’t take much of an imagination to suspect that Obamacare was never intended to work as advertised

      This is a very cynical claim, and people have been making it since the law was passed, but doesn’t it kind of imply a very unrealistic level of competence behind the people who devised the law?

      1. but doesn’t it kind of imply a very unrealistic level of competence behind the people who devised the law?

        Hmm, this is very good point – one I hadn’t thought of earlier. Perhaps a different way to look at it would be that those who devised the law believed ACA would work well. And, once it was shown to work, that would be grounds to ask for more government involvement in health care?

      2. I just said it was never intended to work, I didn’t say it was intended to fail, either. That’s just crazy talk. Whether or not it “worked” had nothing to do with it. It worked to get the government’s foot in the door, gain acceptance of the idea that government should be in charge of running some sort of universal healthcare scheme – and now we’re debating what exactly the scheme should look like rather than whether or not there should be a scheme at all. So it worked just fine if you accept that all it was intended to achieve was getting some sort of program started, no matter how awful, on the grounds that getting anything at all started meant it could never be stopped. Deciding Obamacare isn’t worth fixing, scrapping it and replacing it with some other form of universal healthcare system isn’t going to cause Obama or any Democrat to shed a tear – getting a universal healthcare system is all they wanted and they don’t care what you call it.

        It’s a “stone soup” approach to legislation. Promise you’re going to produce the most delectable soup using nothing but a pot of water and this magic stone and when they complain that the soup’s awful, well, it tastes better if you add some potatoes. And some carrots. Maybe some onion. A little garlic couldn’t hurt. A nice chunk of beef, some salt and pepper, maybe a nice loaf of bread to go with it. By the time you’re done – hey, that stone really is magic! It made this delicious pot of soup all by itself!

        1. Fair enough, but I still think you’re giving them too much credit. Based on the amount of self-congratulatory back-patting that went on at the time, I think they truly believed they had done God’s work. “Important work”, as my progressive acquaintances would say.

        2. This is why democrats should be overthrown, and not debated. A reset is much easier when your enemies are all in prison.

      3. Bingo. They are too dumb to plan this failure.

      4. Bingo. They are too dumb to plan this failure.

    5. I think this is close, but not quite there. I think you assume more planning and intelligence behind the law than was actually involved. I believe the authors of the law didn’t care about the specifics because they’re Progressives, and therefore they believe that there are no problems that can’t be solved by a technocratic bureaucracy.

      Basically, your garden-variety Progressive often confuses goals with plans–“Everybody should have access to inexpensive healthcare”–without fully understanding the subject, particularly with regards to the economics of it, and in the near-religious belief that you can arrive at a desired outcome by simply giving the right bureaucrats enough of the right kind of authority. The last bit obviates the need to understand specifics, since you can just sort of wave the wand of government and magic the specifics into shape via regulation.

      They believe in accountability, but remember, they also believe that the role of government is to make the right choices for people too stupid or untrustworthy to make them themselves, so, naturally, accountability is to the government, not the governed. Thus any lie or deception to the public is excusable.

      1. I think you meant “religious belief.”

  9. kill Jason Vorhees with Freddy Krueger’s corpse

    There was a whole movie about that, you know? I think it ended with a standoff.

    as long as some sort of government program established the general principle that it was right and good and proper that government run the healthcare industry

    What are Medicare and Medicaid, chopped liver?

    Government doesn’t give a shit if they’re driving the car off a cliff, all that matters is that they’re the ones driving.

    Also, what’s the point of commandeering someone else’s car if you’re not going to wreck it?

  10. Government insurance policies won’t change the math on cost.

    Now that we know the actual costs of these plans, budgeting for them will be more difficult, not less, to pass through congress.

    Wasn’t this whole boondoggle supposed to cost less than $1T over 10 years. Obviously that target will be impossible with a government insurance program.

  11. Pretty pictures!

    How does the law of exponents work again?

    1. That chart isn’t close to being right. I’m imagining some version of ‘Back to School’ where Thronton Mellon is exp,aiming about all the stuff in health care the professor forgot. Like kickbacks and government bureaucracy.

  12. The GOP’s total opposition to the law, combined with a lack of clearly articulated alternatives, has rendered the party less trustworthy on the issue.

    Fuck off Suderman. Refusing to a man to vote for Obamacare is one of the few good things the Republicans have ever done. And for their efforts, they get lefty sympathizers like you whining about how they didn’t help to save the Democrats from themselves. You admit up front Obamacare was a horribly flawed idea from the start. How then does the Republicans” refusal to support it reduce their trustworthiness on the issue. The fact that even the biggest government supporting Republicans would support it, makes the Democrats passing it anyway that much more reckless.

    Whatever you think of Obamacare, the Republicans have nothing to do with it. Not a single one of them voted to pass it and Obama has vetoed every effort they have made to repeal it. This is the Democrats’ problem.

    1. I suspect Suderman was alluding to the state of healthcare before the law; with insurers behaving atrociously, racketeering, price fixing, rising costs with worsening service, etc etc. The causative conditions which made this stupid abortive socialist nightmare look palatable to useful idiots, in other words.

      The GOP does deserve some props for their brief moment of rebellion. That they were part of the underlying problem which set these circumstances up, and have done nothing since to address either the new psychotic dystopia or the old and busted rigging is still fair game, was his point I believe. I could be wrong on that, I can only read Suderman’s mind every other Tuesday between the hours of 8:30 and 9. 🙁

      1. They were only “part of the problem” to the extent that they were losers who never succeeded in saving the country from the Democrats’ insane ideas. Other than Medicare Part D, which is a very small part of the health care system, the Democrats pretty much own everything with the Republicans at most responsible for not doing enough to stop them.

        Ultimately, Suderman’s gripe is the Republicans didn’t propose compelling enough programs to keep the Democrats from doing this. That is fine as far as it goes, except that he would never make that criticism of Democrats. Did Suderman or anyone at Reason ever fault anti War Democrats for not doing enough to stop Bush from invading Iraq and imply that they somehow shared the responsibility for the decision and its fallout because of that? Not that I am aware of.

        1. Oh, I am absolutely uninterested in playing “Who’s Worserer – Not My Team!” If it makes you a happy person in and of yourself to see the Republicans as blithe incompetents being picked on by journalists for their blithe incompetence – have at, my good man.

          1. He didn’t say anything of the sort. Just that the ACA is one of the things that actually isn’t a republican fuck up, at all. Which conflicts with part of Suderman’s premise. Which is what I thought we were here to discuss.

        2. It would have been nice if some more Rs had proposed maybe trying out a much freer healthcare market and put forward some legislation to help that happen.

          But I agree, they do deserve some credit for standing against the law.

          I still really don’t get how the damn thing got through the Senate, though. Is there really nothing the Rs could have done to stop whatever trickery was used to get it passed?

          1. I should be thanking you for not throwing up. Well done, you’re a star. You didn’t wet yourself, did you? You’re in the right city. You didn’t say anything overtly racist. You didn’t pull your cock out and start plucking it and shouting “Willy Banjo.”

          2. It would be nice if Washington DC had a better mass transit system or cheaper taxis. That fact, however, doesn’t make the District responsible when I get drunk and run over someone driving home.

            Do the Republicans have their problems? Plenty of them. The fact remains, however, they had nothing to do with the drafting or passing of this disaster. So they are not responsible for it in any meaningful way and their failure to save the Democrats from themselves in no way affects their credibility in pointing out what a disaster this is.

            1. Yeah, I agree as far as that goes. My question is a real question.

            2. No, they’re not responsible for ACA in the slightest, and may even have injured themselves by going after it so bitterly. The constant defunding and repeal attempts almost certainly tainted them in voters’ eyes.

              That fact, even if voters accept it en masse, gets them no closer to doing something about it, and that’s the one question that matters. They still have to pitch an appeal that voters accept. So far most of the legwork in that direction has been done incidentally by the ACA itself: consumers like it less and less the more of it they see. This should be a base Republicans steal with ease, maybe even a home run if they can knock the issue out of the field.

              Instead they’re talking immigration.

              1. The constant defunding and repeal attempts almost certainly tainted them in voters’ eyes.

                Yeah. This is why it doesn’t matter if I vote. That’s the only worthwhile thing they’ve done, to my eyes.

          3. They took an innocuous bill the Senate had already passed and shipped it to the House. They stripped all that language out and inserted the text for Obamacare and got the CBO to declare it “revenue-neutral” so they could re-pass it in the Senate under “reconciliation” rules that can’t be filibustered and only require 50 votes to pass.

            1. That was also after enough votes had been ‘found’ in the trunks of Democrat operatives’ cars to get Al Franken his Senate seat.

      2. Suderman is begging the question though, and assumes maintaining the (shitty) status quo was not an acceptable policy alternative. I’m not the only one who thought that, as craptastic as it was before OCare, it would be worse after its passage.

        Is Suderman going to blame those rascally republicans when Hilary et al pass horrible tax code “reforms” and make an already terrible tax code worse? (Yes)

        I don’t see any reference to the libertarian ideas on reform, so not only is Suderman not doing his job and getting the message out there, but engaging in exactly what he accuses republicans of doing. It’s talking past each other all the way down

        1. That is an excellent point. You are not the only one who thought that. Most of the “crisis” in health care was invented by people like Suderman. US healthcare worked quite well before Obamacare. The vast majority of people in this country said they were happy with both their insurance and their health care. Basically a bunch of self appointed “top men” decided that that people didn’t really know what was best for them and the system needed fixed. Could it have been better? Sure. But most people liked it and as we have now found out, it could have been a lot worse. There was no reason to pass Obamacare other than the vanity of the people involved.

          1. I don’t know if I’d quite say “quite well”. Yeah, it was fine for people who had decent insurance from work. Which means that most people were satisfied.
            But the employer based system had already created lots of the problems that have been made much worse with the Obamacare.

            1. Here is the thing zeb, maybe “works really well for most people” was the best result available? When you start screwing with a system that works well for most people, you are more likely to do more harm than good if for no other reason than there are more people who are happy with the current system and thus can be harmed by changing it than there are people who are not happy with the current system and thus have nothing to lose by changing it.

              1. I’d pick what we had before over what we had now, that’s for sure (although my own situation hasn’t changed appreciably). And maybe it was the best we could hope for.

                But good old market competition should help improve service and lower prices, and that wasn’t happening much in the old crappy system or the new extra-crappy system. I’d have liked at least to feel like that option was on the table for someone.

            2. You know that the government created the exact conditions that made employer provided insurance a thing in the first place, right? The government imposed wage caps so employers used ‘health insurance’ as a way to get around that and attract new or superior talent.

              So, once again the government is stepping into a government created problem to re-fix it by breaking even more shit.

      3. I suspect Suderman was alluding to the state of healthcare before the law; with insurers behaving atrociously, racketeering, price fixing, rising costs with worsening service, etc etc.

        None of which was addressed or changed by ObamaCare. In fact, the pressure/incentives created by OCare to consolidate, both in the insurance and healthcare industries, has made these problems worse.

        1. We are in agreement! Shall we argue about Suicide Squad instead? Because I thought it sucked. Will Smith had more energy in I Am Legend, idek what happened there.

          1. I thought Suicide Squad was a perfectly adequate comic book movie. My expectations were in the mid-range, and they were more or less met.

        2. Which I believe is part of Suderman’s point. I understand the Republicans being pissed that the Dems were initially trying to ram the public option through and produced this turd as a result, but it’s not out of bounds to criticize them for

          The facts are, that the cost of healthcare has been increasing at 2-3 times the rate of inflation for decades, while government spending on it has going up on an average of about 9% a year for about 35 years. The market provides plenty of solutions to fix the monopolistic behavior of the healthcare industry, but Republicans weren’t pushing a single one during the entire Obamacare debate. They’re in no position to whine about the negative effects of Obamacare if they weren’t looking to solve the problem in the first place.

          1. Whoops, should have typed in “but it’s not out of bounds to criticize them for not offering any viable alternatives.”

            Healthcare is expensive as fuck in this country. It’s one thing for complicated medical procedures, but even basic stuff taken for granted decades ago is beyond the out-of-pocket means of most people. I’ve mentioned before that in the 1950s, you could get a normal live birth and two days in a private hospital room for about $1,000 inflation-adjusted. The US wasn’t exactly a third-world country back then. The bill for when our youngest was born last year, same services? $25,000. For nothing more complicated than what was done 50 years ago. Thankfully I have good insurance so we only had to cover about 10 percent of that, but I would have been more than happy to save up $1000 and pay for the whole thing myself without using insurance. In what universe should a libertarian be jumping for joy when the cost of a service is 25 times what it was just six decades ago? This is total regulatory capture and crony capitalism by the healthcare industry and the Republicans punted.

            1. This is total regulatory capture and crony capitalism by the healthcare industry and the Republicans punted.

              You said it better than either Suderman or I could. Nice one.

    2. Yeah, fuck that cocktail-guzzling cosmo. The GOP’s healthcare plan, which is both a comprehensive dismantling of Obamacare, and a set of laws ensuring a free market solution to help make healthcare more affordable is worthy of applause, not scorn.

      1. I don’t care if the GOP plan is to shoot the sick, it wouldn’t make them any more responsible for Obamacare or anymore on the hook to fix it. The facts are what they are. Not everything fits your narrative Crusty. You have like 20 chances a day to piss and moan about the mean Yokals picking on your beloved reason writers. This isn’t one of them. Aren’t they other 20 times enough? Do you have to insert the issue into places where it doesn’t belong as well?

        1. I do love pissing and moaning and pushing a narrative while inserting an issue into places where it doesn’t belong.

          Ultimately, Suderman’s gripe is the Republicans didn’t propose compelling enough programs to keep the Democrats from doing this. That is fine as far as it goes, except that he would never make that criticism of Democrats. Did Suderman or anyone at Reason ever fault anti War Democrats for not doing enough to stop Bush from invading Iraq and imply that they somehow shared the responsibility for the decision and its fallout because of that? Not that I am aware of.

          1. And that is true Crusty. Show me where he has ever made such a criticism of the Democrats. Again, you would do a lot better if you would push your tiresome “you guys just hate Cosmos” meme when it actually applied instead of dragging it out whenever someone makes a criticism of a reason staffer no matter how valid.

            Serious question, do the reason staff ever do anything worthy of criticism in your opinion? I would be curious to hear if they do and have you give some examples of it because I all I seem to ever see you do is bitch and moan when someone criticizes them.

            1. I am flattered you pretend to pay attention to my comments.

      2. Repeal and depeal! Tax cuts are totally different from subsidies.

      3. Show me where petey advocated for that. Was it in the lack of a national health policy part?

    3. It is also that the only government policy on health care that counted was one that had universal coverage as the goal, but it is trying to force universality on the market that is the fatal flaw of Obamacare. There is nothing the GOP could have proposed that would have both worked and satisfied the universal goal.

    4. Yeah, the whole “a pox on both sides” tic (that reason.com readers are given a great deal of) is quite dumb in this case. In resisting O-care the GOP were both prescient and consistent with libertarian principles.

  13. This is no surprise, considering it’s the evil offspring of Obo and that miserable hag Pelosi.

  14. This monstrosity was passed over the objections of the majority of the American people, without a single Republican vote. A Republican won Ted Kennedy’s Senate seat in deeply liberal Massachusetts on the promise of opposing Obamacare. Then, because they lost that vote from Ted, they had to resort to constitutional chicanery to drag the law over the finish line. This thing is owned, lock, stock, and barrel, by the Democrats.
    But Suderman just can’t help, himself can he? Gotta have the false equivalency and throw in a paragraph explaining how the Republicans share blame, when actually, no, they don’t.

    1. Share, no but they do have their own bucket of blame and those are valid criticisms

  15. Yet again we have a ‘libertarian’ arguing that because a party did not advocate for a national health care policy it is to blame for the party that did. Impeccably reasoning.

    Can we just get mccardle? Her pieces usually have some reasoning and aren’t twice self-referential.

    1. I assume that all of Suderman’s non-Trump posts are just him badly paraphrasing things that Megan said to him.

    2. No kidding. If the GOP isn’t willing to get its own Top men, then it can’t complain when it gets blamed for when Democratic top men fuck up. That is really the essence of Suderman’s argument.

      1. Works for vox.

    3. Well, they could have advocated for a free market national health care policy. There’s one place where the commerce clause can be used legitimately to change how things operate. They could have, you know, argued for a free market in health care, or at least major deregulation, allowing insurance to be sold out of state, change how its treated in taxes, etc.

      I didn’t hear a lot of that.

      Still, the Democrats do own the piece of shit we have now 100%.

      1. Certify more drugs as OTC instead of prescription (I’d prefer all of them, but that’s unrealistic). Give pharmacists the authority to prescribe certain low-level medications. Open more medical schools. Give more treatment authority to nurse practitioners. Allow the purchase of health insurance across state lines. Allow individuals a tax deduction for health insurance (maybe; would distort market, but probably less than the current state of affairs).

        1. Yeah, I want to hear about that, not “death panels” and “Obamacare” (remember when that was supposed to be a derogatory name for the ACA?).

          There is a national health care policy, so no-policy isn’t an option now. But policy doesn’t have to mean a different top-down control plan to replace the one we have.

        2. “Allow individuals a tax deduction for health insurance (maybe; would distort market, but probably less than the current state of affairs).”

          It would almost certainly distort the market, but it would also work to decouple insurance from jobs.

          It’s fucking retarded that if I work for a big enough company, I get health insurance tax free but if I work for a small company or own my own, I’m paying taxes on the income I have to use to buy shitty private insurance.

          1. And then people complain about huge corporations.

          2. Uhh…yeah that tax exception is going away for everyone actually. So you’re getting your wish? It’s actually one of the biggest tax hikes in memory. Prepare for the next President to get blamed for that, probably even if it’s Hillary.

            1. Is it really? I hadn’t heard that. Are they going to just completely fuck people or are they going to create some kind of “health insurance deduction” like for student loan interest?

              And it will be nothing compared to the tax hike when the retarded masses finally get the Canadian or UK single-payer system that they seem to be yelling for.

        3. That’s at least better.

      2. So every time gary johnson does not articulate a free market solution to a problem i expect reason to hold him to task.

        I’ll be waiting a long time.

  16. Until someone actually begins to think of the entire problem here, there is no possible policy solution. We have split ‘health care’ into so many pieces that neither a price signals/system nor a voting signals/system can possibly work now. An employment-based system leaves massive holes and cannot work. A year-by-year ‘open enrollment’ system makes the entire industry uninsurable because of moral hazard and the nature of ‘health care demand’. A risk-pool that is split into tens of thousands of pieces is nothing but a risky puddle. A government system that is designed to buy votes cannot possibly create the rationing/signals that are necessary to allocate capital. An insurance system that disconnects patients/consumers from providers/doctors cannot be the basis for any market system. The nature of the product itself – and the near-absolute information assymmetry – means that a market won’t be able to come up with an equitable (define it however you want) solution completely on its own.

    1. The nature of the product itself – and the near-absolute information assymmetry – means that a market won’t be able to come up with an equitable (define it however you want) solution completely on its own.

      Ok, I define:

      Equitable = I get as much care as I am willing and able to pay for, you deliver as much care as you are willing and able to provide, we resolve disputes via contract and tort law

      Et viola, the market will deliver on “its own”. (how do millions of people acting as independent agents count as a single entity?)

      You are free to work with others to form other arrangements, such as risk pooling, indirect/negotiated payment, charitable care, etc. But you don’t get to force me or anyone else to participate in these arrangements.

      1. You are part of the charity care and risk-pooling system whether you like it or not. Because hospitals themselves were CREATED (mostly by religious denominations and secondarily by surgeon groups and tertiarily by municipalities and only in distant fourth for-profit corporations) in order to pool risks, spread costs, and provide charity care.

        And ‘we resolve disputes via contract and tort law’ specifically FAILS under conditions of information assymmetry. But hey keep spouting cute irrelevant theories about how the world has never actually worked.

        And you haven’t even addressed the big elephant about health care. Which is – no one gives a crap about it until they are deathly sick – and then there is no limit to what they want. 50% of health care spending is done in the two years before death. Which pretty much means that if it is going to work, it has to involve open-ended lifetime-type ‘contracts’ which can’t be resolved until death.

        And I’ll throw your ‘equitable’ right back at you then – what are you gonna do about a sick infant who hasn’t accumulated enough to pay their medical bills? You may be perfectly OK with letting them die. But honestly – are you really gonna contract with a DOCTOR who has that same attitude? Because if they have that attitude about sick kids, chances are very high that you are a much less sympathetic case when you get sick.

        1. Don’t talk about “cute irrelevant theories about how the world has never actually worked” while bringing up bullshit hypotheticals. Maternity, neonatal, infant, pediatric etc. care isn’t paid for by the child, it’s paid for by the parents. If an infant is left to die, it’s not the doctor’s fault, it’s the mother and father’s.

          Information asymmetry exists in every single economic transaction. It is part and parcel of division of labor. Crowing about how bad it is is irrelevant; nobody can resolve the asymmetry between you and and some other economic actor except yourself. If it’s a problem, then go out and get informed. It’s easier than it’s ever been, the constant changing of the law by the government notwithstanding.

          And yes, tort and contract law, along with some quasi-contractual things like living wills and powers of attorney, have worked in the real world. It’s the system we (mostly) have and have had for quite some time.

        2. Moreover, “50% of health care spending” is entirely beside the point. So what? Nobody pays for health care in the aggregate except the government, and then only for direct spending like Medicare. That spending pattern does not reflect what an individual does spend or would spend if left to his own devices.

          Also, the observation that such spending “is done in the two years before death” is rather banal. That people are more inclined to pay when they feel more is on the line is hardly surprising. The better question is, why should I pay for your last 2 years, or vice versa?

          Your post is rife with the insinuation that people are evil and/or stupid. Is that the problem, a lack of public morality? Well, all the more reason to take money and power out of the hands of government. How a system built by evil and stupid people would converge to anything but more evil and more stupidity is beyond the reasoning of mortal men.

          1. “50% of health care spending” is entirely beside the point. So what?…the observation that such spending “is done in the two years before death” is rather banal.

            Its not beside the point. The ENTIRE workforce/employment sector of healthcare is a struggle over how much a generally healthy population will subsidize the sick who are the economic demand for health care. People who are actually sick – don’t get hired. People who are within two years of death are too sick to work. The 18-65 population has the lowest mortality rates. This isn’t the seeds of a ‘free market’ – it is cherry picking.

            Govt spending in the US is unique in that it doesn’t ration care much. Ppl choose their own specialists and incur expenses on their own initiative which is the habit/expectation they created for themselves during their employment years. And has incurred a $100 TRILLION liability into the future via intergenerational debt. Any ‘free market solution’ has to incorporate that problem going forward. ‘Health care’ cannot work as one-year contracts – cuz the ‘demand’ side only occurs at the end of a lifetime.

            Which again raises the ‘equitability’ issue – which you dismissed by washing your hands of a sick infant and blaming their parents. That’s fine for YOU. But I ask you again – are you really going to contract with doctors who have the same concern for someone else’s life that you do? And rely on them (and your supposed ‘contract’) to save your sorry butt when you get sick?

  17. Remember Obamacare is far, far more than just the individual exchanges.

    Obamacare is also the business mandates. It is the federally-imposed standards on what constitutes ‘real’ health insurance. It is the requirement that insurance providers spend a certain amount of premium income. It is a tax on medical devices. It is the (delayed, as of now) tax if a company provides benefits in excess of what a federal bureaucrat thinks appropriate. It is the huge expansion of medicare. It is defining ‘full time’ as 30 hours a week. It is defining a ‘child’ as someone as old as 26.

    While most of the media is focused on the failure of the exchanges, let’s not forget that Obamacare is screwing people in many ways.

  18. Well, there’s a guy over at the NYT, That’s the NY fucking Times, peanuts!, who says that it IS working great and he has a Nobel Prize! Does anyone here at this peanut gallery have a Nobel prize??? Huh, huh, yeah, that’s what I thought! Peanuts and Trumpets here, only peanuts and Trumpets!

    1. He doesn’t have one either.

    2. If only we could come up with a solution that worked well for all the people who aren’t government mouthpieces as well as those who are.

  19. What is really needed is a politician with the guts to say “What’s wrong with the health care system is almost certainly ha;f a century or so of government ‘solutions’ to the health care problem. Repeal all federal law on health care, health insurance, and so forth, and wait five years to see what – if any – underlying problems remain.”

    Not going to happen. I would expect Shrillary to make a porn film with a baboon before I saw that or anything like it.

    1. So……you’re saying there’s a chance?

    2. Well, you hate the children. End of story.

    3. But that is not a health policy, it is an snti-health policy!

    4. Oh sure. Let the corporations run the show. Soon as someone gets sick they will be dropped from their insurance. Corporations care about profits, not people. Get rid of these laws and there will only be healthcare for the rich.

      Besides that, healthcare is a basic human right. It is immoral to profit from basic human rights. That is the root of the problem: profits. Let government run the entire healthcare system without any profits going to the rich, and it will be totally affordable because government doesn’t siphon off profits to the rich.

      All reality-based people know this.

      1. It is amazing to me how so many people think “the corporations” are a hive mind, who all act in concert with one another to deliver the same end. As though no one else has ever thought to make money another way until the people’s politician comes along and shows them how.

        The only time every market actor does the exact same thing is when the government forces them to.

        1. They do have a like mind. They exist to enslave workers and force products onto consumers, while making obscene profits. They exist to lay waste to the land and create fiefdoms where they are the masters and the people are their serfs. They are like the feudal lords of old. That is what happens when corporations run amok. Only a socialist government can prevent capitalism from becoming corporate feudalism.

          Duh. Everyone knows this.

    5. What’s wrong with the health care system is almost certainly ha;f a century or so of government ‘solutions’ to the health care problem. Repeal all federal law on health care, health insurance, and so forth, and wait five years to see what – if any – underlying problems remain.

      According to quick research, doctor house calls began to decline in the 1960s. Hmm, were there any government medical programs developed in the 1960s?

      Yeah, yeah, I know…correlation/causation AND simplistic but not an unreasonable connection.

      1. AMA and HMO are dirtier acronyms than ACA. Forget Medicare, as bad as it is; the “professionalization” of medicine is what turned it from a customer-oriented business into a government-controlled service.

      2. Doctor house calls declined as phone service became more universal. It didn’t start in the 1960’s, but much earlier. There may have been a sudden and steep decline in the 1960’s. But the driving force was that doctors were reluctant to get out of their warm beds if nobody was worried enough to come fetch them.

  20. Can someone remind what the purpose of the exchanges even is?

    1. They’re supposed to increase competition by something mumble mumble HEY LOOK OVER THERE, GAY MARRIAGE!

    2. Squirrel traps?

    3. Getting Democrats elected?

  21. Can someone remind what the purpose of the exchanges even is?

  22. Speaking of bad policy

    “Anxiety” may be too mild a word for the feeling across the city ? better call it dread ? that gentrification and displacement are unstoppable forces. The mayor’s big idea is to rezone neighborhoods and require developers to include permanently affordable apartments as part of the deal. That plan, combined with strong rent regulations and tenant protections, should be enough, Mr. de Blasio argues, but many people fear that he’s wrong.

    Rent control and “tenant protection” will put an end to gentrification and inequality, just wait and see.

    This country originated as a maelstrom of creative destruction. Now, our “thought leaders” and their publicists fetishize stasis. “Oh, no! Those shithole neighborhoods are being overrun by people with jobs! It’s tragic.”

    1. Whites leave neighborhood = White Flight. That’s bad, m’kay
      Whites move into neighborhood = Gentrification. That’s also bad, m’kay.

      1. Why do you want to displace poor blacks and other minorities? Racist.

    2. permanently affordable apartments

      What the fuck does that even mean? Affordable to whom?

      1. It means Hugo Chavez will give everyone a house and a free laptop, and then, primo, then we really get down to business!

      2. Based on previous history of rent control, the local councilman.

    3. I had a bet with myself before reading the full text of the post or clicking the link that the city in question was either Seattle, San Francisco or New York.

      Damn, I hate it when I’m right.

  23. a lack of clearly articulated alternatives

    Not having a Five Year Plan for comprehensive top down management of a huge chunk of the economy is EXACTLY THE SAME as having no policy ideas whatsoever.

    Got it, Pete.

  24. There is another pernicious effect to come. Say you are an insurer with 200,000 members in a state exchange. You have learned over the years that you have to severely narrow the network in order to lose less money. You’re not really profitable but have stemmed the losses. Now you learn that all of your competitors who covered the other 500,000 on the exchange have pulled out leaving you as the only choice. You could end up with 700,000 members for a network designed for 200,000. What happens? Long waits for care, implosion, or most likely both. Lots of pissed off people for sure.

  25. Uwe Reinhardt, a prominent health economist

    I would like to point out, that the entire existence of “health economists” is an unnecessary fiction.

    What we need analyzing the market are “economists”. There’s zero difference between the Smart Phone market and the Heart Surgery market. None, zero.

    1. Well, economists all have their areas of specialization.

      But it’s a good observation that many of these varieties of economists only exist to study the screwed up messes created by lots of mucking about.

      Heart surgery market should be the same, but since almost no one knows what they actually pay for heart surgery, it looks a bit different.

      1. I suppose it’s reasonable to point out the way things are vs. the way things ought to be. For instance, the Soviet Union had economists analyzing their 5 year plans.

        1. I suppose it’s reasonable to point out the way things are vs. the way things ought to be.

          I like to think so.

  26. OT: my crim law professor instructs you to vote for your clearly established betters

    I can just cross out Missouri and write Cooley right?

    1. Too bad your criminal law professor didn’t have any advice on HTML links.

      1. I always SF them

        1. [less than]a href=”link”[greaterthan]Text[less than]/a[greaterthan]

        1. hoose. Choose for yourself. Choose for your children. Choose for posterity. Choose because abstention ? and a vote for the Greens or the Libertarians is an abstention ? confers no elevated moral stature.

          Whoa. Ok then.

          1. Blindfold or no blindfold?

  27. What we need analyzing the market are “economists”.

    But economists are heartless bastards who might advise the government the money ought to be spent efficiently.
    You know, instead of spending Xk dollars on liver transplants for geriatric alcoholics, they might spread it more broadly, as on children with broken arms or poor eyesight, for example. Things which have a longer time horizon.

  28. Some tweaks have been made at the margins, mostly small changes that further destabilize the law’s policy scheme in order to bolster it politically (the Obama administration’s decision to grandfather in many plans in order to keep its promise that those who like their plans can keep their plans, for example).

    Sorry, but this is just false. The administration chose a very narrow definition of grandfathering, very few plans still qualify, and the promise to let you keep your plan has not been kept because it was a lie on day one and has been a lie every day since.

    Because this existential question has not yet been resolved, the political dynamic has remained unchanged. And what that means is that fixes or reforms of any kind lack the requisite political support to pass.

    Note how this is framed as the obdurate refusal of the Repubs to give up on their opposition and just save the Dem’s bacon by fixing the law, rather than the obdurate refusal of the Dems to admit that they passed a law that they didn’t understand and that was never going to work.

    1. Obamacare was based on two assumptions that are to be frank insane. First, it is based on the assumption that getting people insurance will somehow lower overall healthcare costs. That sounds so reasonable until you understand what it is really saying. It is saying that the key to getting the cost of a good or service down is to force people to purchase insurance for that service. WTF? That is so ridiculous it is hard to even type it with a straight face.

      The other premise that Obamacare is based on is the idea that we could reduce healthcare costs if only we could get people to partake of preventive care. That is something only an intellectual could believe. No one wants to be sick even if they can afford treatment. So if there were a way for preventative care to keep people from being sick in the first place, there would be no need to provide it because people would already be doing it.

      The entire thing was insane from the start. And the fact that the media took it seriously, shows how amazingly stupid journalists actually are.

      1. One more: the goals of reducing global cost and the goal of increasing preventive care are contradictory. Preventive care is mostly tests (which cost money) on asymptomatic people that produce a lot of true negatives (the vast majority being asymptomatic for a reason), a fistful of false positives (which cost money to clear up), and a small number of true positives (which cost money to treat). Where the savings are in a program that costs more money is a mystery.

        1. The idea, and it is full of Top Men thinking, is that preventative care reduces the need for treatment later on, and thus reduces the overall cost.

          It’s reminiscent to me of engineering methodology whereby the cost of solving a problem is (believed to be) magnified the further down the development/production chain it is identified and resolved. But this requires that you can identify the problem before it really becomes a problem, and that you don’t waste time trying to guess at what the problems will be and “solving” things that aren’t going to be problems. Even experienced engineers fall into these traps all the time.

          And medicine isn’t engineering.

          1. But this requires that you can identify the problem before it really becomes a
            problem

            Yes and no. It requires that you can identify the problem before it causes catastrophic harm. This is a methodology designed to reduce the impact of latent defects.

            Medicine usually isn’t dealing with latent defects, but transitory diseases and deficiencies. Only on rare occasion is the cause of an illness solely associated with a latent defect. This is exactly why preventative medicine only makes sense for a handful of illnesses (like cancer).

            1. This is exactly why preventative medicine only makes sense for a handful of illnesses (like cancer).

              Does it even work then, though? The whole “chop off your boobs if you have the BRCA gene” kind of backfired, didn’t it? Moreover, what kinds of cancer have strong predictive indicators and inexpensive preventative care? Is it really cheaper to catch cancer early, or is it just that your survival chances are much greater? Death is cheaper than life, generally speaking.

            2. The calculation that you have to make, even with cancer, to determine whether preventive medicine is going to reduce costs is a little complicated. The big, unspoken issue is “save costs over what time period”? On a shortish time period – certainly one year, maybe as many as five or ten, there’s no way it saves money. Its only when you posit that early detection will result in a cheaper treatment regime that you can start to argue for savings, and those savings are typically in the out years, when a late-stage cancer will cost more to treat than an early-stage cancer.

              (1) The cost of the increase in testing

              plus

              (2) The cost of following up on false positives

              plus

              (3) The cost of treating true positives discovered by the increased testing

              less

              (4) The amount saved because the treatment is cheaper than it would have been if the disease hadn’t been discovered early. Don’t forget to discount the more expensive late-stage treatment for the time value of money.

              Its very hard to get to actual savings with preventive care. It may be right for other reasons, but not because its cheaper.

    2. , rather than the obdurate refusal of the Dems to admit that they passed a law that they didn’t understand and that was never going to work

      This really can’t be said enough.

      Imagine leaving on a long roadtrip with a nearly empty gas tank, and a bunch of people are warning you that you’re going to get stuck in BFE with no gas. Stuck by the side of the road an hour later, you have the temerity to call the people that warned you, demanding a roadside rescue, while blaming the whole thing on their stubborn refusal to drop everything they’re doing and drive out with more gas.

      1. While still berating you as a heartless monster who wants poor people to die for not getting on board with the ill-fated trip at the start

    3. The GOP has never formulated a plan of their own that could have competed with Obamacare, so they became the party of “we hate you, poor people” instead of “hey, our plan will actually help you, poor people.”

      The GOP’s “the law is bad” strategy has never worked in their favor. Even though the law is beyond terrible they are still the party of uselessness.

      1. Yeah the GOP didn’t have the Top Men for big plans! Stupid fuckers don’t know we need more plans!

        This is why libertarians are good for talking Liberty but not for getting it. The answer to this freedom killing bill was to kill it. That was the only options, pass or fail. Sitting on the side saying both sides are equally bad is a exercise in ego masturbation.

  29. Something amusing from NYT:

    “Your first duty is to the survival needs of the self: food, water, shelter,” my father would solemnly tell me. “Your second is to the emotional needs of the self: rousing up fear and respect from your enemies and so-called allies. Only then do you take care of the casual entertainment needs of the self: traveling abroad to golf resorts, laughing at funerals, buying Hammacher Schlemmer gadgets. Now, tell me you love me.” I’d express how much I loved him. “That’s so funny,” he’d say, “because I don’t love you at all. Neither does your mother. Actually, no one does.”

    On his deathbed, ailing from the Drano his best friend had poured into his coffee, he pulled me close and whispered, “Promise you’ll always support the narcissistic sociopathic party,” before flicking me in the eyeball, spritzing Binaca in his mouth and dying.

    Sure, I rebelled a bit in college, briefly considered narcissistic psychopaths, had a fling with sociopathic narcissists and, of course, experimented with libertarianism. But on Election Day, I still voted narcissistic sociopath up and down the ballot. Self-aggrandizing oratory, the mercurial backstabbing of loyalists, callous disregard for anyone else’s well-being: The party’s bedrock principles would bring a tear to my eye if I had the capacity to feel tenderness.

    1. I guess they need to fill some space, those NYT guys…

    2. That was fairly amusing.

  30. In any case, experts?even some who generally favor the law and its goals?are starting to question the stability of the exchanges.

    If you’re just starting to question the stability of the exchanges, you aren’t an expert. Anybody with any knowledge of how health insurance actually works in the real world knew the exchanges, as designed, were at serious risk of a death spiral.

    1. The legislation was always intended to fail, exactly as it’s doing.

      Suderman is too stupid to realize that, because he’s an Obama momma.

  31. You can’t suck all the time; not even if you’re the New York Times.

  32. As a party and political institution, the GOP wasted years both before and after the law essentially declining to make a positive case for any kind of health policy at all, leaving open the door for Democrats to pass the reform that they did. The GOP’s total opposition to the law, combined with a lack of clearly articulated alternatives, has rendered the party less trustworthy on the issue.

    I’ve logged on to Reason, right? Not the Huffington Post? I never knew it was a hallmark of Free Minds and Free Markets to insist that, unless they were proposing a comprehensive plan from the government, we shouldn’t take someone seriously on a topic.

    1. The infection of a libertarian publication with Top Man Do-Somethingism has been sad to see, Bill.

    2. Sadly, Pete Macadoodle Suderweigel doesn’t have a free mind, and he doesn’t believe in free markets.

    3. As I said, they’re simply not dropping what they’re doing and heading out to the remote sands of I25 with a can of gas to rescue the Democrats’ asses.

      For instance, Diane Reynolds has a viable alternative to the plan, it’s just not politically viable: Dramatically slash all government intervention in healthcare markets, including but not limited to subsidizing small hospitals and all anti-competitive legislation which is designed to keep healthcare limited and prices high.

    4. Do you ever read the words that people actually write and not the ones you imagine they really meant?

      Deregulate and let the market do its thing would have been a perfectly good comprehensive plan for health care. I don’t see where anyone is insisting that the plan must be one of government control over the healthcare system.

      The Republicans could have pushed market reforms and deregulation of healthcare (it sure as hell wasn’t any kind of functioning market before). But they didn’t in any coherent way. So I think it’s a fair criticism.

      1. And again every time a libertarian makes a compromise solution i expect you to call them on it. For instance gay marriage.

      2. I’d see your point if this argument happened in a vacuum. It’s not. Suderman has a record on the topic.

        The fact is that the GOP has offered a “plan”

        https://reason.com/blog/2016/06…..shows-that

        Suderman wrote it off as “barely a plan at all”

        Let me offer a suggestion, if that is barely a plan at all, what the hell is it you think “Deregulate and let the market do its thing” qualifies as?

        1. Suderman isn’t much of a libertarian, I can’t argue there.

          But even in the article you link, he seems to be mostly complaining that the Republican proposal contains a lot of the bad things that are in Obamacare, not that their proposal isn’t top-men-ey enough. Quite the opposite, really.

  33. Anybody with any knowledge of how health insurance actually works in the real world knew the exchanges, as designed, were at serious risk of a death spiral.

    Anybody (like… you know… the President) who doesn’t grasp the distinction between INSURANCE and CARE is a drooling imbecile.

    1. The President is an analytical guy! He’s so smart!

  34. Here is the stupid thing. To fix the health care system in a reasonably free marketish way is fairly simple.

    1) Eliminate the tax deduction for employer provided health care and eliminate any language in any law that in any way advantages employer provided insurance over private health insurance.

    2) Allow ANY organization to sponsor health care plans in the way employers do today.

    3) Everyone over the age of 18 is required to have a Health Savings account that they can deposit up to $2000 per member of their household into on a before tax basis (and as much as they want over that on an after tax basis) but they are not required to deposit anything into it.

    4) Current Federal Health programs are canceled, the $1.01 trillion we spend on health care will be divided up with 700 billion being allocated to direct contributions to peoples HSA’s and the remaining $301 billion going into a new type of Medicare system.

    5) The new Medicare system will cover everyone in the country but it will ONLY cover a select list of very high cost diseases. Essentially things that cost hundreds of thousands per year to treat.

    1. 6) Federal contributions to HSA’s will be on a sliding scale based on income and family size align with…

      Bottom economic quintile – $4000 per year
      2nd quintile – $2800 per year
      Middle quintile – $1800 per year
      4th quintile – $1000 per year

      The actual numbers for each household would vary based on household size but a median sized household in each of those groups would get that amount.

      7) Money in your health savings account in excess of 10x the average annual health expenditure for your household size may be donated to close relatives (parent, child, grandparent, grandchild, sibling) HSA with no tax impact.

      8) Money in your health savings account in excess of 20x the average annual health expenditure for your household size can be donated to anyone else’s HSA with no tax impact or withdrawn with a tax penalty of 25%

      1. You left off:

        Allow insurance companies to sell across state boundaries. Use the interstate commerce clause as intended for a change.

      2. Yeah, that’s great. The Republicans should have been proposing that all this time, in addition to bashing Obamacare and trying to repeal it.

          1. Then you haven’t been reading their ‘poor plans’ as petey describes them. Many of those ideas come straight out of gop and conservative proposals.

    2. Posted above, but these are always my suggestions:

      Certify more drugs as OTC instead of prescription (I’d prefer all of them, but that’s unrealistic). Give pharmacists the authority to prescribe certain low-level medications. Open more medical schools. Give more treatment authority to nurse practitioners. Allow the purchase of health insurance across state lines. Allow individuals a tax deduction for health insurance (maybe; would distort market, but probably less than the current state of affairs).

    3. Changing to this system leaves people the option of buying insurance or self insuring and paying out of pocket, it makes actual insurance far more affordable because it removes the risk of a $10 million dollar disease from the equation, while adding far more competition into the group insurance market and if you index the hsa contributions to inflation instantly fixes the problem of ever growing federal health expenditures.

      Is it a perfect system? No. Is it a libertarian one? Not really no. But, it is a hell of a lot better from both a functional and a libertarian system than what we have now.

    4. HSAs (where you get to keep the balance) + emergency insurance go a long way to giving most people most of what they want.

      The thing that few people will accept is that you’re not going to get $100,000 or more of care year-over-year from now until the day you die for $10,000 or less in premiums.

      We have never had a problem of emergency care in this country. Even before EMTALA, there were charitable hospitals that would provide such care.

      What we have a “problem” with is people who are going to suck down lots of dollars in care for extended, indefinite periods of time, who have never paid anything close to that amount and never will.

      No system can deliver it. Ours is the only one that even pretends to. In all of the glorious social-democratic universal-healthcare countries, there are limits, whether official or unofficial, to how much time and money can be spent on an individual’s care. What nobody admits to is that, while you “don’t have to worry about” whether or not you can pay for your care, that’s because somebody else already decided for you.

    5. Essentially things that cost hundreds of thousands per year to treat.

      Epipens?

    6. Require providers to publish price lists so people can more easily shop around for things like lab tests and operations.

  35. For those of you who think the hole in the bottom of the budget ship isn’t big enough yet, that lying hag has a cutting torch ready to make sure it capsizes to port in the next year of so:

    “Hillary Clinton is rolling out a comprehensive plan to address millions of Americans coping with mental illness. She’s pointing to the need to fully integrate mental health services into the nation’s health care system.
    Clinton’s campaign is releasing a multi-pronged approach to mental health on Monday. Her agenda would focus on early diagnosis and intervention and create a national initiative for suicide prevention.
    It would also try to integrate the nation’s mental and physical health care systems to focus on the health of each individual in a seamless way. It would also aim to increase access to community-based treatment opportunities.
    Clinton would also convene a White House conference on mental health within her first year in office if she’s elected.”
    http://www.sfgate.com/news/pol…..190085.php

    1. Welp, that ought to give me job security until I retire.

    2. If memory serves, comprehensive mental health care was part of HillaryCare in the 90’s and one of the reasons it imploded.

      1. And yet here she is, eleventy years later on the cusp of becoming the leader of the free world. Nothing succeeds in government like… can’t remember the last part.

    3. “It would also try to integrate the nation’s mental and physical health care systems to focus on the health of each individual in a seamless way.”

      Just wanted to mention, nothing says “seamless” like 35 forms, in triplicate.

      1. Oh please, they have moved into the 21st century.

        there won’t be 35 forms in triplicate just a requirement that mental health professionals buy an electronic health records system that costs $25,000 per seat, takes years of training to use properly, lacks sufficient security features and forces the doctor to spend half the visit interacting with his computer rather than the patient.

    4. The problem is that psychiatry is largely a load of shit. I could do as well as and psychiatrist I’ve encountered at semi-randomly trying different medications on people until I find something that sort of works.

  36. “The debate over whether the health law should even exist has never been resolved, making policy fixes all but impossible.”

    Meanwhile, reality is treating the progressives’ lies on the subject like a jailhouse bitch.

    If Trump wins, they’ll no doubt blame the inevitable collapse on him.

    If Hillary wins, I doubt she’ll be able to sell more of the same.

    1. Luckily, barring something so big I don’t know how to describe it or even imagine it, it’ll be on Hillary.

      1. I don’t know how to root for somebody to win that has abused her office so thoroughly in such a corrupt way, but give her enough rope and she will inevitably put it around her own neck.

        Jimmy Carter, rightly or wrongly, is credited with making government bureaucracy as a solution to our problems a laughing stock. Even if Hillary’s inevitable corruption scandals dominate our attention (and what’s the point of being President to Hillary if she can’t line her pockets?), she’ll have a hard time escaping policy responsibility for whatever comes next.

        1. give her enough rope and she will inevitably put it around her own neck.

          Fortunately, there’s no shortage of people in and out of government will decline to pull the lever, and will actually cut the noose off of her neck. No matter what.

          1. They’re gonna look like Baghdad Bob.

            Who are they going to blame for the smoking crater where the exchanges used to be?

            Obama?

            She’s already set to take office as the most hated woman in America.

            1. No, the intransigent congress made up of Republicans.

              Case in point: Who does Maduro blame for Venezuela?

              1. I don’t think people are going to buy that from Hillary.

                Just because they bought it from Obama, doesn’t mean they’ll buy it from Hillary.

                He was the black messiah.

                She’s a used care salesman.

      2. From a political perspective, I don’t think the Republicans should do anything about healthcare. They should treat it like that scene at the end of V for Vendetta when everyone just stands there and watches Westminster explode. Let the progressives blab, “Blah, Blah, Blah, even while the whole ObamaCare system goes up in flames.

        Remember that guy during the Iraq War, Baghdad Bob? He continued to deny the Americans were anywhere near Baghdad–right up until a squad of American soldiers stormed his broadcast and took him into custody. Hillary Clinton is like Baghdad Bob. She’s been pushing for precisely what we’ve got since 1993–and she’s still saying we need more?

        Here’s Bill Clinton pushing HillaryCare in 1993. Read that text and tell me he’s not talking about what we got with ObamaCare.

        “The fourth principle is choice. Americans believe they ought to be able to choose their own health care plan, keep their own doctors, and I think all of us agree. Under any plan we pass, they ought to have that right.

        —Bill Clinton

        http://economix.blogs.nytimes……care-1993/

        If you like your doctor, you can keep your doctor!

        LOL

        That’s the political angle, anyway. The humanitarian side of me sees that an awful lot of poor and sick Americans are going to suffer because of this, and that’s awful.

    2. If Hillary wins, I doubt she’ll be able to sell more of the same.

      Hell, they never sold the first one to the public. Why would not being able to sell its expansions to the public make any difference?

      And now, they have a statute littered with grants of rule-making authority. They can pretty much do what they want at the agency level, Congress be damned, so the lack of Dem majorities in Congress isn’t even an obstacle any more.

      1. I don’t think Hillary can sell that shit like Obama did.

        She isn’t trusted.

        Good will towards her is already worse than it is for anyone else in the country, save Trump.

        When Obama took office, his approval rating was north of 60%.

        Hillary hasn’t had an approval rating of more than 45% since January.

  37. Why are insurance done on a county by county basis? Is this due to the community rating requirement? If so, how incompetent do the law’s architects need to be that they didn’t see this?

    1. how incompetent do the law’s architects need to be

      I don’t know incompetent they needed to be, but I do know how incompetent they actually were. Remember, if it was a good idea, it would not have to be mandated by legislation.

    2. They’re pretty fucking incompetent.

    3. Yeah, community rating.

      A proven, BTW, risk factor for death spirals.

  38. “In recent months, Democrats have settled on support for a “public option”?a government run health insurance plan that would compete alongside private insurers in the exchanges.”

    This issue is that they’re all public options–even the so called “private” options are actually covering the losses providers and insurers suffer caring for people on Medicare and Medicaid.

    There needs to be a private option.

    There needs to be at least one provider/insurer who isn’t required to have a contract with a Medicare intermediary, who isn’t required to accept Medicaid, and who is allowed to operate pharmacies, ERs, etc. that refuse admissions to Medicare and Medicaid patients.

    There needs to be a private option.

    1. I can see this on cable news already:

      “Did you guys hear about Donald Trump? Now he’s against letting poor people use the ER!!!”

      I’m guessing that’s why we don’t have a private option.

      I ain’t no objectivist, but sometimes life does imitate Ayn Rand.

    2. Ken, its actually possible right now for a provider to refuse to sign up for Medicare and Medicaid.

      There’s a non-trivial number of physicians who have refused. I know of one hospital that doesn’t take Medicare or Medicaid, and I believe there are children’s hospitals that don’t take Medicare.

      For most hospitals, though, its a non-starter. You just can’t run a hospital if you aren’t getting paid anything for 30% or more of your patients. We have nine figures in various reserve accounts, and our hospital would close in less than two months if we had to use that money to cover the costs of Medicare and Medicaid patients.

      1. I’ve been out of the loop for a while, but I believe it’s a function of accreditation.

        Joint Commission accreditation is a prerequisite for a Medicare and Medicaid contract, but I don’t believe Joint Commission will certify you unless you have a means to accept Medicare and Medicaid patients as an acute care hospital. The local health board frowns on turning away Medicare and Medicaid patients, as well.

        I remember when our private hospital was circling the drain, the first things they tried to do was shut down the ER. They came in and forced us to open our ER again.

        Then when people showed up to the ER with Medicaid, we started calling an ambulance to take them to the hospital on the other side of town.

        Once they stopped us from doing that anymore, we had to end life as an acute care hospital and change into a lock down mental hospital. The reimbursement rates on 5150s was pretty good, and they generally didn’t need low reimbursement procedures and tests.

        Some specialty hospitals that aren’t acute care or depend solely on specialty referrals can dodge Medicaid patients, but I’ve never heard of an acute care general hospital otherwise being allowed to operate while rejecting Medicare and Medicaid patients. Take a look at these guys.

        https://thrive.kaiserpermanente.org/medicaid

        1. Joint Commission accreditation is a prerequisite for a Medicare and Medicaid contract, but I don’t believe Joint Commission will certify you unless you have a means to accept Medicare and Medicaid patients as an acute care hospital.

          I’ve worked in non-JC accredited hospitals. The accreditation substitutes for state accreditation on your Medicare application. I’m not aware that being a Medicare hospital is required for JC accreditation, although JC (or state) accreditation is required for Medicare participation. There are other accreditation organizations out there, too.

          I remember when our private hospital was circling the drain, the first things they tried to do was shut down the ER. They came in and forced us to open our ER again.

          You have to have an ED in order to have a state hospital license in every state that I know of.

          Then when people showed up to the ER with Medicaid, we started calling an ambulance to take them to the hospital on the other side of town.

          If they were still a Medicare hospital, they were subject to EMTALA, and that is a flat-out, prima facie EMTALA violation. They’re lucky they didn’t get fined and put under federal supervision.

          1. “If they were still a Medicare hospital, they were subject to EMTALA, and that is a flat-out, prima facie EMTALA violation. They’re lucky they didn’t get fined and put under federal supervision.”

            Fining a dying hospital for refusing to provide expensive ER services to Medicaid patients at a loss is like fining a drowning man because he isn’t breathing.

            The local population was all Medicaid (Medi-Cal). Why not just seize the hospital and close it instead?

            From Harbor UCLA to King Drew, all the hospitals in the area had the same problem–both of which were either closed or taken over by the government.

            Anyway, whatever regulatory framework it was, whatever law it is, the essence of the problem is Medicaid and Medicare. If private hospitals were free to exclude people on those programs, hospitals would be competing on price. Instead, they do everything they can to gouge private pay patients to make up for the losses they take providing care to people on those programs, and insurers do everything they can to protect themselves from that gouging.

            If there is no way for a private provider to insulate themselves from treating Medicare and Medicaid patients, then there is no private option.

            The problem is not that we need a public option. They’re all public options.

            The problem is that we need a private option, and there isn’t one.

            1. P.S. That ER is now gone forever.

              Medicaid didn’t keep that ER open for the general public.

              All those people who die on the way to the hospital across town drive right past the old one–most of them never realizing they’d already be in an ER if it wasn’t for Medicaid.

              Medicaid shut down that ER forever.

              Thanks Medicaid!

      2. I’ve been to all private hospitals. They operated like hotels. The looked like hotels both inside and outside.

        They were in Mexico.

        That’s the way hospitals act when they’re not subject to Medicare and Medicaid patients.

        They don’t have to take anybody on the government program, and they don’t take anybody on the government program.

        http://starmedica.com/_EN/_HOS…..da_12.aspx

  39. I guess the “just stop messing with the healthcare market” ship has sailed.

  40. Can’t we just pass a law that makes it illegal to be unhealthy?

  41. Suderman’s arguments here sound exactly like the endless loop that you get from progs; i.e., since the Republicans didn’t pass significant healthcare reforms (hello, Medicare Part D, anyone?) in the years prior to 2009, they must now kowtow to whatever Hairy Reid and Nancy Pelosi want to attempt to “fix” the abomination of a bill that they forced through Congress without a single vote from the opposition party in either house of Congress.

  42. The faster we get rid of the ACA, the better.

    Good analysis.

  43. They could have, you know, argued for a free market in health care, or at least major deregulation, allowing insurance to be sold out of state, change how its treated in taxes, etc.

  44. Hmmm. Been through my copy of the Constitution THREE TIMES just now, and I STILL can’t find any authority for the federal government to do ANYTHING regarding health care/health insurance.

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  46. ObamaCare does exactly what it was intended to do; destroy the healthcare market, clear the way for single-payer nationalization of healthcare. Trump and Clinton both support single-payer. That what the baby boomers want and the younger generations will pay the price.

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