The GOP’s Endless War on Obamacare-and the White House Delay

The official reason given by the Administration for delaying, by one year, the Affordable Care Act’s mandate that employers with more than 50 full-time workers provide insurance coverage or face fines, is that employers need more time to implement it. The unofficial reason has more to do with the Republicans’ incessant efforts to bulldoze the law.

Soon after the GOP lost its fight against Obamacare in Congress, it began warring against the new legislation in the courts, rounding up and backstopping litigants all the way up to the Supreme Court. Meanwhile, House Republicans have refused to appropriate enough funds to implement the Act, and have held a continuing series of votes to repeal it. Republican-led states have also done what they can to undermine Obamacare, refusing to set up their own health exchanges, and turning down federal money to expand Medicaid.

The GOP’s gleeful reaction to the announced delay confirms Republicans will make repeal a campaign issue in the 2014 midterm elections, which probably contributed to the White House decision to postpone the employer mandate until after the midterms. “The fact remains that Obamacare needs to be repealed,” said Senate Republican leader Mitch McConnell, on hearing news of the delay.

Technically, postponement won’t affect other major provisions of the law — although it may be difficult to subsidize workers who don’t get employer-based insurance if employers don’t report on the coverage they provide. But it’s a bad omen.

The longer the Affordable Care Act is delayed, the more time Republicans have to demonize it before average Americans receive its benefits and understand its importance. The GOP raged against Social Security in 1935 and made war on Medicare in 1965. But in each case Americans soon realized how critical they were to their economic security, and refused to listen.

Robert Reich, former U.S. Secretary of Labor and Professor of Public Policy at the University of California at Berkeley, has a new film, “Inequality for All,” to be released September 27. He blogs at www.robertreich.org.

177 replies »

  1. “But I would prefer a policy of allowing basic care, in a basic (safe, clean) setting that almost everyone can afford.”

    That is one of the reasons premiums should be high deductible and risk adjusted combined with a mechanism to prevent new illnesses from pushing one out of the pool. Subsidization should exist on top of that in a fashion that only minimally interferes with market dynamics.

    “And I would like to know how much is expected to be spent on the “looking for trouble” part that’s required”

    Sandra, that shows you are a thinking person. Preventative services should be targeted based upon the individual not the shoe size. The ACA was playing games trying to attract votes with this provision as the cost/benefit can be outrageous.

  2. Interesting, Al. When visiting the UK a few years ago with a group studying comparative health policy, many in the group were shocked at the multi-bed wards and the generally unattractive surroundings in the hospitals. But I wonder if we had a conversation here about what we want to spend money on, if we would choose the level of care we have here in the US. We’ve become accustomed to it, and I personally would not find it offensive if those who had unlimited funds could access anything their hearts desired. But I would prefer a policy of allowing basic care, in a basic (safe, clean) setting that almost everyone can afford. You look at the high deductibles of the plans on the exchange, and it looks like almost everyone will never utilize their insurance. Most will be on Medicare before they incur large expenses, and then they will utilize different funding streams. Of course, always exceptions, like with car insurance. And I would like to know how much is expected to be spent on the “looking for trouble” part that’s required – preventive services that are screenings for disease. Why isn’t that optional? I’m happy to keep myself as healthy as possible to avoid as much interaction with the healthcare system as possible, but I can’t see that getting a mammogram is going to keep me healthy. I don’t fault anyone else for utilizing all those services if that fits their lifestyle and philosophy, but it’s just not for me. And I don’t think it’s wise social policy to pay for it for everyone and expect them all to use these types of services.

  3. I was just recently abroad and my significant other had an accident. The country I was in had global budgets so the surgery they proposed was totally inadequate as was many of the ways they offered care. The doctors and nurses were excellent and probably could have done as good a job as we had in the states, but due to the global budgets of that nation I had to have a private jet to fly my significant other home. They did not have many of the things I am used to in the states and they used older, but cheaper technology. Does it make a difference? Absolutely as the old technology would have left problems remain and probably would have required a second surgical intervention.

  4. I think what’s mostly unsaid is that most countries with “universal access to healthcare” have global budgets. I personally think that’s the way to go – like living in the real world, rather than trying to manipulate people into rationing themselves yet still think they have “the best in the world” without limits. The first time I actually saw this discussed was recently in NEJM:


    J Frank Wharam, et al, say in their second paragraph:

    “In the ACA, Congress chose market-based cost controls over measures that are common internationally, such as global budgets. Mandating coverage while requiring affordable premiums without enacting other cost-control mechanisms almost inevitably gives rise to increased cost sharing as the simplest mechanism for reducing premiums.”

    The ACA and High Deductible Insurance – Strategies for Sharpening a Blunt Instrument” NEJM 369:1481-4 (October 17, 2013). I’d be interested in knowing if this is explored elsewhere – I don’t keep up on this as much as I have in the past.

  5. Lisa, when insurance carriers cannot underwrite or manage risk, they are no longer insurance companies. And, Reich continues to be a shill and a coward.

  6. Change which may be needed can be good or bad. In the case of the ACA change is very bad.

  7. Wrong! Wellness exams might be good medicine but they have been proven to increase the total cost of healthcare.

  8. What are you talking about? The private sector is only private when it creates the prices it charges for its goods and services.

    The ACA is a rule book set by ignorant and ignoble people that should disappear from the public arena. They don’t have the slightest idea of how goods and services are produced nor do they know how to distribute them.

  9. Aurthur, your beef is with the insurance companies. Change was absolutely necessary and if the system isn’t working, we have nobody to blame but ourselves for not fixing it.

  10. MaH, healthcare is too expensive for a lot of reasons, but wellness exams are not one of them. Early detection keeps costs down.

  11. Pat,
    Our rates didn’t go up, they stayed the same. They were too high for poor coverage before (as an individual buying on a private exchange), and now they are too high for much better coverage. IMHO we need a catastrophic coverage option for everybody (so nobody has to face financial ruin in case of an accident) and I can pay for my own flu shot.

  12. The ACA depends on the private sector (insurance companies) to set premiums. How the prices roll out will make or break the ACA system. The law can be modified, but ultimately this is a test of whether using the private sector is a workable solution or not. If you go to the website and compare the rates from North Dakota to the same person if they live in Wyoming, you will see what I mean. Right now I wish I lived in North Dakota.

  13. The new bill in Co Senate bill 60 has effectively put a bounty with required and rewarded actions to file fraud charges against providers and billers with no evidence in regards to Medicaid fraud. Physicians are now being scared off from submitting bills with fear of baseless fraud charges. I know this because a family member spent last wed. in jail with no charges against her and told she needed to confess as others had. The people she was told confessed are still doing business as usual and this is obviously a lie.
    Gestopo anyone.

  14. “You seem to think that when there is Tsunami in Indonesia or an earthquake in Turkey or in Japan the U.S. is the only nation sending help.”

    Uwe, I know other places showed up, but their wallets weren’t as thick and their pledges weren’t always paid. I do understand what you mean by being tax deductible, but I have also heard people, maybe you, stating that Americans are under taxed compared to others so if that is the case then the dollar amount given by Americans was even higher. By the way a lot of Americans that give take a standard deduction so the amount given doesn’t affect their taxes

    You are quibbling as to where the charitable money goes. The problem you have is that we give so many multiples of what is given by the French or the Germans that you can remove many of these contributions and the multiples still remain. I won’t include the Canadians because they are far more generous than the French or Germans even though they have health care insurance just like the Germans and the French. Your excuse is therefore a very bad one and should be given the same grade as the excuse ‘the dog ate my paper’, an F.

    The fact that the Germans and the French were at the lowest end of the chart is in part explained by you because “because everyone there has access to health care.” First let me correct your statement for they are insured and insurance doesn’t guarantee equality of access. In any event it is possible that this over dependence upon government makes people tight with their money and not willing to separate from it without a bit of government coercion.

    You make a big deal about foreign aid. You say: “I am amazed, though, how quickly you write off foreign aid as a form of charity. Do you find data on that inconvenient?”

    I don’t find it inconvenient for I don’t include foreign aid in with charity from my government and it certainly doesn’t count as charity for private individuals. Furthermore, even though it isn’t a huge part of federal expenditures I question whether we should be giving such monies in the fashion we do.

    I am proud of the charity Americans provide both in time and money and in permitting many people from around the world to settle here especially when they are discriminated against in other parts of the world.

    At present you seem to have a deep seated dislike of America. Maybe this evening you had an American dinner you didn’t like and you are reacting to it just as it is reacting to you. I don’t know, but maybe you should take an aspirin and go to bed. The Uwe at the table isn’t much fun to be with tonight. I hope you wake up tomorrow in a better mood.



  15. Al,

    You seem to think that when there is Tsunami in Indonesia or an earthquake in Turkey or in Japan the U.S. is the only nation sending help. I can see why you might think that, because nations generally show on TV only their own countrymen helping. Are you sure Europeans do not show up for help at those places?

    As to what we call charitable giving in the US, you evidently have not read my posts in the NYT on that. First of all, a sizable chunk of what we call charity is actually public expenditure, because charitable giving, so called, is tax deductible.

    Secondly, I would not define donating money to museums or the Lincoln center or even to churches charitable giving, but merely voluntary financing of public goods. As I note, the true charity in charitable giving in the US is quite small.

    Germans, the French and Canadians, for example, do not have to rely on charitable giving for health care because everyone there has access to health care.

    But if you want to believe that Americans are the most charitable people on earth, I would not want to rob you of that belief, if it makes you feel good.

    I am amazed, though, how quickly you write off foreign aid as a form of charity. Do you find data on that inconvenient?

  16. Bob, universal insurance is not the same as access to health care. Based upon one’s definitions the US has universal healthcare. These are foolish terms unless defined.

    “What the heck, if we eliminated the bizarre filibuster rule we would already have more social programs. Without any revolution in our national character.”

    I want to help people in need not create programs to make me feel good about myself.

  17. Peter1: “What have those myopic comments to do with states rights or the civil war or my comment?”

    Your argument against the south “slave labor or segregation.” If your argument wasn’t so one sided I wouldn’t have commented.

    Now what was myopic about my statement concerning the progressive and Liberal fantasy of keeping American blood pure (eugenics)?

  18. “Where is the money going? Have you ever seen our lawns?”

    Uwe your lawns are beautiful and obviously well fertilized. That is something that seems to come naturally from institutions of higher learning so no expenditures are necessary.

  19. “There are some things we Americans should not read.”

    Is that the Constitution or the Declaration of Independence?

    Uwe, Danes are wonderful people, but that doesn’t mean that we should change the data or is that what you advocate? But, I wasn’t talking about our foreign aid programs rather unexpected assistance to nations that faced catastrophic tsunamis, earthquakes and the like. Charity.

    For your information I am not one that supports the way we provide foreign aid, but charity is a different story especially when it comes voluntarily from individuals. You do understand what I mean about voluntary as opposed to coercion, right?

    Now if you can explain your point again?

  20. Al:

    Further on foreign aid. See Figure 1 in the article at this linkhttp://www.fas.org/sgp/crs/row/RS22032.pdf. It shows how little Denmark gives relative to the rest of the U.S.

    I urge you, however, not to read the rest of the article and especially not to look at Figure 2.

    There are some things we Americans should not read.


  21. What I was trying to get across is this:

    – having universal social insurance programs in a nation does not mean that the citizens of that nation are all kind and tolerant.

    What it means is that at one point in time, the political groups that want social programs had a large legislative majority and strong leaders…….and they were able to put universal programs into law.
    (e.g., FDR and LBJ)

    At the same time, the fact that a nation does not have universal programs does not mean that all its citizens are mean and selfish. It only means that the opponents of universal programs have a lot of legislative strength.

    What the heck, if we eliminated the bizarre filibuster rule we would already have more social programs. Without any revolution in our national character.

  22. “But, why do you think bigotry is limited to the south?”

    Where did I say that?

    “It was the northern textile workers that passed a minimum wage so that jobs would not move to black persons in the south. Who but the progressives advocated eugenics in great part to prevent the propagation of what was considered inferior people entering the American blood stream. That was aimed at blacks as well.
    Ted Kennedy the great Liberal who demanded equality for blacks permitted black inequality on his own streets in the town of Palm Beach.”

    What have those myopic comments to do with states rights or the civil war or my comment?


  23. Al,

    You are right about the foreign aid. I once saw a bar graph comparing the dollar amount (PPP $s) Denmark gives in foreign aid with the dollar amount America gives, and our bar dwarfed Denmark’s. I found it puzzling, because on the surface the Danes seem such nice people.


  24. Yes, Peter, I don’t shoot from the hip, but I know Bob and he is an honest broker. He made a statement and I presented some things I believe are factual. If Bob chooses he will put them together and we will then better understand what he was trying to get across. It is Bob’s conclusions I am interested in, not my own.

  25. We all agree that slavery and bigotry were wrong. Even most of our founders knew that and many tried to end it in the compromise. It wasn’t ended until the Civil War and the country paid dearly for that black mark.

    But, why do you think bigotry is limited to the south? It was the northern textile workers that passed a minimum wage so that jobs would not move to black persons in the south. Who but the progressives advocated eugenics in great part to prevent the propagation of what was considered inferior people entering the American blood stream. That was aimed at blacks as well.

    Ted Kennedy the great Liberal who demanded equality for blacks permitted black inequality on his own streets in the town of Palm Beach.

  26. “Does Canada truly have “solidarity in health care”? Does not each province handle their health care needs differently? Is there not a marked difference between the care provided to Canadians and the Inuits along with other natives? Is there not a marked difference between the haves that can get care in the US or jump queues from the have nots?”

    Al, you seem to have researched this already to form an existing opinion. Maybe you can give us your search results to see who you are believing?

  27. “Much of the fight revolves around the issue of states rights”

    The right of a state to continue an economy on slave labor or segregation?

  28. Peter1: ” Biggest drag on advancing this country forward is southern mentality of still fighting the Civil War.”

    Much of the fight revolves around the issue of states rights and that issue is nation wide.

    “…in order to prevent misconstruction or abuse of its powers, that further declaratory and restrictive clauses should be added:…”

    Amendment X

    “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”

    It is easy to demonize southerners, but a lot less easy to demonize the tenth amendment.

  29. Bob, I am asking this as a question, not part of a debate. Does Canada truly have “solidarity in health care”? Does not each province handle their health care needs differently? Is there not a marked difference between the care provided to Canadians and the Inuits along with other natives? Is there not a marked difference between the haves that can get care in the US or jump queues from the have nots?

  30. Sandra I think we overuse the term “universal care” without a unified definition of what it means. I don’t know that any western nation is terribly good at managing health care resources though the way they do it may seem more organized since the Europeans seem to use and accept force more easily. I don’t think the American mindset permits that type of control by government. Neither does the Constitution, but that is another debate.

    Along with reasons you are alluding to we have so much trouble dealing with Medicare expenditures because our type of federal government is incapable of handling this type of social program. I presume that is why the founders left it out of the Constitution and created a division between the feds and the states.

  31. Confusion makes the experts seem brighter and causes large expenditures by our federal government on those experts.

    Health care isn’t all that difficult unless people are trying to turn lead into gold wanting to get something for free.

  32. Matthew,

    We’re not penalizing any student for not turning in their paper. We just assign an F to it.

    As to turning in papers electronically, a university would have to be crazy to allow it. Maybe Yale or Harvard allows it, not Princeton.

    If the student sends it electronically, the poor prof has to print it out and use university-bought paper. By requiring students to submit printed papers, the cost of printing it, including the paper, is shifted to the student (or the student’s Mom & Dad).

  33. “It took that long to overcome the Southern Dixiecrats”

    Not overcome yet Bob. Biggest drag on advancing this country forward is southern mentality of still fighting the Civil War.

  34. I know that several collective tongues are in several collective cheeks on of these posts, but I would lo head off one misconception —

    namely, that national policies are always traceable to national character.

    Canada has solidarity in health care, but certainly no solidarity about the sovereign status of Quebec. Germany has tolerance for sick persons in health care, but has been home to some of the worst racial and religious intolerance in history.

    America has no solidarity in health care, but since about 1950 has extended Social Security to everyone over 65. (It took that long to overcome the Southern Dixiecrats and include farm workers and domestics.)

    I believe that national laws are created by political initiatives and institutional opportunities. Whereas national character flows and changes much more slowly.

  35. Uwe, I understand that if there were a thermonuclear war, that’s a pretty good excuse for not turning in my Econ paper. But what about if I don’t turn in a paper because I’m sure there is about to be a thermonuclear war? Surely that’s an economically rational position, and you can’t penalize your students for being rational economists, can you?

    And BTW I assume that most term papers are delivered in electronic format. Are dogs eating students’ computer files these days?

  36. Uwe,

    “It could mean selfishness, for example.”

    …And when tragedy hits around the world, which government generally provides the most relief? Yet it is not just money America has supplied but it has also used its army, navy and air force to help other peoples in need. That costs bundles as well. But we cannot forget that when these catastrophes occur the American people give privately as well, more so, I believe, than the people of any other country.

    Yet, you wish to label the American people as selfish in a backhanded way.

    “My view is that when the going gets tough in America, the tough usually run to the government for succor –”

    That is a very superficial interpretation. Some believe in more self reliance, but if they are forced to pay into a system why shouldn’t they take advantage of it?

    I will agree that most are asking too much of their government and our leaders are pandering to the most juvenile emotions of a great people, but that too passes. Take note of our history and how the Americans were always downplayed by the Europeans, but in the end always towered.

    I would be careful of overplaying your scenario with regard to libertarians. Many or most believe in some government involvement and most people are a blend of ideologies. You seem to be generalizing to the extreme.

    “Individualism” often just reflects a lack of civic duty here.

    That is totally wrong. Individualism in context with the discussion at hand means civic responsibility without coercion. That is how this country was built. Perhaps civic duty elsewhere requires coercion or at least that is what you seem to be saying.

    P.S. Maybe the dog ate the post you submitted and the editors substituted this one.

  37. Seriously, I don’t think we can truly have “universal healthcare” that works without a global budget of some sort. I do think the Europeans are very good at managing healthcare resources – I personally think that’s impossible with an open-ended benefit as it appears to be here. I think this is why we have so much trouble controlling Medicare expenditures. But we’re a long way off from thinking that in this country. Perhaps it would take an unprecedented crisis to get Americans to accept that.

  38. Ms. Raup:

    I recently gave a talk to an utterly august audience, titling it


    So you are in good company.

    Love and warfare are easier to comprehend.

  39. Thanks for explaining. I have run into this analysis before, I’m afraid. I don’t know enough Europeans to assess their collective attitudes, but I do know quite a few Americans. I respectfully disagree with your assessment, but that probably comes from the fact that I view them through the lens of the culture with which I identify. I’ve heard some interviews with Greeks who are finding it more difficult to obtain healthcare, and in many ways they also sound confused about healthcare economics – or perhaps economics in general. Not that I’m an economist.

  40. Ms. Raup:

    I resorted to the thermonuclear war hypothesis merely as an act of kindness.

    The real story is less flattering. You say that relative to Europeans Americans are more individualistic, which could mean many thinks. It could mean selfishness, for example. You also claim that relative to Europeans, Americans are less risk averse. Really?

    My view is that when the going gets tough in America, the tough usually run to the government for succor – whether it is people who could have bought health or flood insurance but went without it, or people who build houses where they should not, or bankers who defecate all over their balance sheets, figuratively speaking, and then ask government to clean them up again. It is the American way, I am afraid to say.

    Now you can see why, sweet and polite fellow that I am, I use the thermonuclear theory instead. It has a certain elegance.

    I recall a segment on the Jim Lehrer show in which Judy Woodruff had a conversation with a handful of real Americans (in 2009). A Libertarian in the group who professed his disdain for government and said he did not need it said he was poor and unemployed. Judy asked him what he would do if he got sick. “Go to the emergency room of the nearby hospital,” he said, without even realizing how absurd his view toward society was. And Judy is much too polite to take him to task for his twisted view of society.

    I have never seen or heard Americans who rail against a mandate to be insured also rail against EMTALA. Too many Americans seem to think that with rights do not come commensurate responsibilities. That is also true, of course, in connection with health behavior.

    In an interview published in Health Affairs (http://content.healthaffairs.org/content/29/8/1442.full?sid=232fdde1-abfa-449e-84dd-98b1eaf4039f) the former Swiss Secretary of Health was asked how he could defend a mandate on individuals to be insured. He replied:

    “That’s easy. We will not let people suffer and die when they need health care. The Swiss believe that in return, individuals owe it to society to make provision ahead of time for their health care when they fall seriously ill. At that point, they may not have enough money to pay for it. So we consider the health insurance mandate to be a form of socially responsible civic conduct. In Switzerland, “individual freedom” does not mean that you should be free to live irresponsibly and freeload from others, as you would put it.”

    It amazes me why so many Americans cannot follow that logic. “Individualism” often just reflects a lack of civic duty here.

    Because I would have great respect for true Libertarians, if I should ever come across some, I have proposed a US health system that can accommodate the Libertarian’s dream of freedom, but also holds him or her responsible for their own misery, should it strike. See http://economix.blogs.nytimes.com/2012/06/29/health-care-solidarity-vs-rugged-individualism/ . Under the proposed regime, we could all be happy.

  41. Matthew:

    I do accept thermonuclear war as an excuse for missing papers, because I simply cannot believe that there are so many dogs dumb enough to eat paper.


  42. That disappoints me, Uwe. I hear from economists that “people act rationally”, and what makes sense to me is that we look at what drives the calculus here vs. Europe rather than talking about what we think young people think. Why would young Americans think thermonuclear war more than Europeans? And can you truly characterize populations with such a broad brush? That’s nuts! I think American culture is more individualistic and therefore we are less risk-averse – perhaps we have not experienced homeland war and think everything will always turn out okay. I don’t think young Europeans are responsible for saving for their healthcare because they’re thinking about growing old; policy decisions were made decades ago. Now, in the U.S., policy is also made by old people who probably, when they were young, thought the world would be blown up before they grow up. What I’ve noticed is that young people are young people around the world – variations across each population, but all with the same hopes and dreams for their futures.

  43. Thank you for your recommendation. I don’t want you to think for a moment that I only blame the person who over-leveraged his home. Not for a minute do I believe they were the only one’s at fault. They foolishly allowed themselves to think that government was there to protect them when more correctly they should have believed that government was protecting Wall Street.

    We, the people, rely too much on leaders that are incompetent and self serving. We are permitting a fascist state to grow and we have noted an uptake in this speed of change in the last decade. I think (only read reviews etc.) Smith’s conclusions lean towards the side of corporatism and that IMO leads to fascism.

    As a side note regarding the $40,000 individual. Look at Florida and all those people that leveraged their futures based upon the belief that Florida real estate could only climb. At the time I was investigating the real estate market in certain areas. I walked away and the next time I looked there were for sign sales and foreclosures everywhere. It was sad to see so many lose everything on a gamble.

  44. Uwe,

    “This belief helps me understand U.S. health care.”

    IMO there are so many better explanations that I am unnerved by the conclusion you draw. On an anecdotal basis I see nothing close to what you are describing. Has this opinion been studied?

  45. “You really believe that a person earning $40,000/yr doesn’t know they can’t afford a half a million dollar house?”

    They may be that stupid – but their lender should not be that stupid. Lenders are supposed to assess loans for payback despite what borrowers might think they can handle – hence the fraud.

    I’d suggest a book titled – “Who Stole the American Dream”, Hedrick Smith.

  46. I believe that the main difference between young Europeans and young Americans is this:

    Young Europeans conjecture that with high probability they will grow old.

    By contrast, young Americans think that with high probability thermonuclear WWIII is just around the corner, wiping out everybody, so that going deeply into debt and insisting on medically underwritten health insurance premiums makes perfect sense.

    It can explain why life-cycle health insurance models are de rigeur in Europe but not available in the US.

    This belief helps me understand U.S. health care.

  47. I would like to bring up an issue that I’ve never seen addressed when speaking of a free market health insurance (like auto or life insurance) vs. something more government-mandated and/or controlled. As you age, you are nearly without exception going to run into significant healthcare costs, primarily out of your control no matter how “preventive” your behavior. We all would like to fall asleep and not wake up after an entire lifetime of no health problems, but that is just not going to happen, so any actuarial healthcare insurance policy will be more and more expensive as you age. For auto insurance, that doesn’t happen – you don’t necessarily have more claims just because you age. For life insurance, you purchase it for future benefit when you are less likely to die so, if you’re lucky, you’ve paid in a substantial amount before you die and you more than likely won’t get more than what you paid in. If we had a true insurance model that allowed you to purchase it without having your premium increase as you age and take on more health problems, that would make sense for people to purchase. Right now if you’re a 20 year old, you don’t think you’re purchasing the health insurance you’ll use when you’re 80, so what’s the point of paying for older people now? And once you’re forced to purchase insurance or pay a penalty, you probably aren’t thinking, “Yes, I’d love to pay 10 times more for my insurance than the penalty even though I’m not likely to use it because all those older people need my premiums for their care.” For two good reasons – (1) there’s no belief that the same is going to be done for you; and (2) it’s so expensive you’re giving up a great deal of purchasing power to have it. If this is going to work, there has to be a way that this makes sense to every population. Back in the ’90’s it may have looked like you had to satisfy the “stakeholders” because of their political power – hospital associations, medical and other professional associations, pharmaceutical companies, insurance companies nursing home association, etc., etc., so the only way to get health reform was to buy them off. I think that was “fighting the last war”. Now, people need to buy into whatever is implemented, and that means it doesn’t “bankrupt” (or overburden financially) healthy people. I am hoping that something like what Truman did with government contractors during WWII will happen – bring in the stakeholders and give them a global budget to work with that’s reasonable, and see what kind of system can be created that works for Americans. There has to be a solution that stops this political bickering between the “right” and “left” perspectives and that’s based on our basic values. Is that too hard to do?

  48. “How do you know that?”

    Uwe, I am sure your little grandson’s love thinking about those mice eating that big glob of cheese that we see almost every night before we sleep. Have they decided which type of cheese it is? The God Apollo11 can tell them when the time has come.

    You tell me that the NSA hasn’t yet caught me and ask “Or thinke, that the moon is made of gréene chéeſe” (JH 1562). I await with great anticipation that communication from John of Goodman.


  49. Al:

    You write: “By the way the moon is not made of cheese.”

    How do you know that? I just wrote my two little grand sons a long, illustrated letter proving that the moon is, so, made of cheese. And there are mice up there as well. I had pictures of that as well.

    I’ll send John Goodman the letter and he can forward it to you, as he knows your e-mail address but I don’t (even the NSA doesn/t).


  50. Peter1, I am not as concerned with health care costs as much as you are. I am concerned about providing necessary care without spending a ton of pooled funds on those that can spend and waste their own money. In my mind a lot of health care is a luxury item including a lot of health care that I receive.

    I believe that the market place should manage most of our health care concerns. I believe government can have a roll, but its roll should interfere with the market place as little as possible. I believe Hayek had a similar feeling, but I am not sure. Perhaps Uwe is a bit more knowledgeable of Hayek’s works than I and I note he is aware of our postings and trying to help you out.

    “Why did you need to negotiate with the hospital to reduce and forgive your obligations if you had insurance?”

    That is a change from the questions I am most frequently asked such as ‘why is the sky blue?’ or ‘is the moon made of cheese?’. Not all insurances are low deductible. They didn’t forgive me the money. They realized their actions were reprehensible and decided to forget about it. I didn’t care one way or the other, but I was willing to spend any amount I had to not to pay them the ridiculous fee they demanded. They were very embarrassed.

    “Most of that was lender fraud.”

    You are a true Obamanite. Always blame someone else and don’t take personal responsibility. Leave Nancy P and H. Reid to catch the greased pig in the mud while you laugh at them. You really believe that a person earning $40,000/yr doesn’t know they can’t afford a half a million dollar house? By the way the moon is not made of cheese.

  51. You have it backwards. It is the burden of the party that wishes to impose a burden on another to prove his case. I don’t think Dr. Reinhardt suggested anything different.

  52. Oh, Mr. Madison Chair, you totally misjudge me, but you are classy. Why would I think Germans are stupid or ignorant? Maybe you have one of those complexities (:-)) like the inferiority complex. Absolutely no need. Let me refer you to a book by (what you might call) a complete right winger, Thomas Sowell. What do right wingers know anyway? (Maybe economics?) He wrote Migrations and Culture(?) a decade or so ago. Read it and you will be proud of your heritage. Imagine that, you agreeing with Thomas Sowell.

    But I do wish to make it clear. Germans are not stupid, but that doesn’t mean they can choose for themselves a health care system that would work for the US. But, Mr. Madison Chair, you knew that already.

    I thank you for this robust jousting. You have always been kind and a gentleman.

  53. Thank you Uwe. You are indeed a friend and made me see the light. It is good that we all help each other. You are an economist and good with numbers. Can you help me balance my check book?

  54. It is true that Germany has had some form of national health benefit since the time of Bismarck, so that gives a little time for trial and error.

    Also, Germany and Japan and England built their current national systems after the devastation of World War II. The effect of the war was to wipe out many vested interests, and it also wiped out the right-leaning political parties.

    Still and all, the Germans do point out one way of insuring all citizens with multiple insurance companies and few if any citizens in debt over health care and (by US standards) quite moderate costs.

    As Dr Reinhardt suggests, the burden of proof rests on us Americans if we feel that the German method is wrong.

  55. “but rather than destroy the marketplace I would manage those groups separately with the eventual goal of mainstreaming everyone.”

    How would you “manage” those groups? How does that reduce costs?

    “any attempt at universal insurance should be focused on the young.”

    For the most part the young don’t need insurance, that’s why it’s so cheap for them. The young get old and the older you are the more you get pre-exist and the more you need/use health insurance.

    “I even carried it when I lived in a slum and didn’t have enough money for a city bus, TV, entertainment, home furnishings, car, good clothing etc.”

    That’s hard to believe. Why did you need to negotiate with the hospital to reduce and forgive your obligations if you had insurance?

    “How did that type of thinking go for all those people that bought homes they figured they could afford a number of years into the future?”

    Most of that was lender fraud.

  56. Al

    So do you think Germans are stupid or ignorant to have that kind of system, rather than our great American system?

    Just curious.

    And classy (Princeton — need I say more?)


  57. Al,

    Peter1 evidently was just worried that you might be uninsured and exposed to financial risk. Why do you call that lack of class? Now, knowing how well inside you are, Peter can sleep in peace.


  58. Peter1, Yes I believe insurance should be handled on a risk basis. That preserves the marketplace. Of course that means we have problems with certain groups, but rather than destroy the marketplace I would manage those groups separately with the eventual goal of mainstreaming everyone.

    We have no choice but to manage the pre-existing problem and that is why any attempt at universal insurance should be focused on the young. Community rating is bad because it causes death spirals, unnecessarily high premiums, and destroys the market place.

    I believe in paying for things as you go. It appears that you pay for things based upon your expected future earnings. How did that type of thinking go for all those people that bought homes they figured they could afford a number of years into the future?

    “how come you’re uninsured”

    How come you are so nosey? It is not becoming, but since you have asked so many times and already demonstrated a lack of class, I will respond. From the time I left home I always carried health insurance. I even carried it when I lived in a slum and didn’t have enough money for a city bus, TV, entertainment, home furnishings, car, good clothing etc. I carry it today to protect my assets.

  59. “The young are charged higher than their risk as a type of tax to pay for others. That money is not being used to secure level rates for them later in life.”

    Well you’re concern for the future of the young is commendable but then you’re for our present system of insurance of assessing premiums based on risk? The young and healthy get the best rates and the old and sick get the worst?

    How do you feel about Obamacare getting rid of pre-exist rating and establishing community rating?

    By the way, under Obamacare as the young get older they will benefit from the same rating for the young as they had to take pressure off rates for them when they get old.

    So how come you’re uninsured – the present insurance rating system not working for you?

  60. Peter1, I am have been totally consistent on this blog. You just see to do too much interpretation of another’s words. Stop reading the Book of Soundbites and start thinking in terms of concepts.

    The young are charged higher than their risk as a type of tax to pay for others. That money is not being used to secure level rates for them later in life. Chances are at the rate we are going we won’t leave them with these entitlements, but we will leave them with a lot of debt.

    What difference does it make if I am insured or not? We are dealing with health care policy not my personal health insurance needs. You are a nosey fellow.

    I don’t support policy just because it supports my interests. I love this country so I support the policies that made it great and will keep it that way.

  61. “Not really. It is penalizing the young.”

    Al, you never seem to be consistent in what you advocate – and hence my earlier comment about your shifting sands of reason. As well you never expand on anything you advocate in an attempt to convince us.

    You stated you wanted individuals rated one time, if you advocate that you can’t also say Obamacare penalizes the young for charging them more to spread the risk. If individuals are to be rated one time they’ll have to accept higher rates when young to get lower rates when old.

    I come back to a question – are you uninsured? Please tell us.

    If you are uninsured are you going to welcome subsidies under Obamacare, and lower rates because the young pay more and the sick don’t get rated.

  62. @Peter: “Isn’t that what Obamacare is trying to do?”

    Not really. It is penalizing the young.

  63. Al, it sounds like some features of German health insurance would please you. Premiums are level over life. Companies cannot shed the sick through targeted rate increases.

    Companies with healthier insureds actually give up some of their profits to a reinsurance fund, which assists the companies with poor claims experience.

    Anyone who wants the basic plan pays 7% of income. So does their employer. There are absolutely no rules about 50 employees, part time hours, and all the nonsense of the ACA. No retail chain can avoid these payments.

    Individuals who make a high salary (I think the level is about $85K in US dollars) can buy a private plan instead.

    Good or bad, I cannot say. But America is light years away from this level of regulation. I think you have an enormous challenge to create an equitable insurance system in the US.

  64. “We need to rate individuals one time and that is why it is essential that we concentrate on insuring the young.”

    Isn’t that what Obamacare is trying to do?

  65. @Bob: “However, the free market in health insurance from 1955 to the present has been all about letting healthy groups buy cheaper insurance”

    Bob, that is the problem with insurance. You can’t have other people pay for your house if you buy fire insurance for it after it burns down. That is the same with health insurance. The flaw we can correct is one that penalizes the individual that suddenly becomes ill and who already carries insurance. We need to rate individuals one time and that is why it is essential that we concentrate on insuring the young.

  66. The costs of that liver transplant caused the employer’s health insurance premiums to rise to $30,000 per family, and that was from a non-profit co-op not a major insurer.

    The employer had to drop their plan. A few employees got onto the pre-ACA high risk pool in MN, which was a good one. Other employees had large financial problems when they needed care.

    Maybe this is an argument for larger insurance pools, so that one employer is not devastated.

    However, the free market in health insurance from 1955 to the present has been all about letting healthy groups buy cheaper insurance, or self insure, and tough luck for the unhealthy groups.

    This is not left wing canard, it has just been the pursuit of self interest. Read the book Strong Medicine by George Halvorson (president of Kaiser) for a good history of this.

    There are many areas of life where the free market makes nearly everyone better off. I contend that health insurance is not one of them.

  67. @Peter1: “But Al, isn’t that the private “competitive” market you seem to keep telling us will solve health care costs?”

    Absolutely not. We have not had a truly private market at least since WW2. Government control underlies the entire health care industry. They start by controlling who can get the tax deduction and under what circumstances. That lead to third party payer which certainly doesn’t represent a free market that is more organic in nature.

    “By the way it appears you’re uninsured??”

    One way or the other, what difference does that make? In any event that demonstrates how unaware you are of how people might be insured. Example: A person has to pay out of pocket until he meets his deductible.

  68. @Peter1: “Al, I have been on this blog almost since it’s inception and yes my comments are in “black and white”, as many long time posters will attest.”

    Peter1, so far where we have engaged I have not been impressed by what I have seen so the laments I hear from you in this post might very well be due to your inability to appropriately converse with one that is not of similar belief to you.

    I note your quotation with regard to markets. It doesn’t take much to find something to quote. To understand it takes more. All different sectors of our economy have some of these same problems. Nothing is perfect, but the market place functions better than a socialist economy. That has been proven by history.

    “That’s why no other country in the world has chosen the U.S. model ”

    When the US was founded then too the rest of the world had chosen differently. Yet through two world wars the west that you wish us to follow had to be bailed out by the US and even fed. Those present at the Jonestown massacre that drank the Kool-Aid must have felt like you, ‘everyone else is doing it’, drank it and died. Those that didn’t were killed anyway on the say so of their despotic leader who like you didn’t believe in personal choice.

  69. “People without insurance are frequently scr-wed. It’s horrid. Cash should be king, but in this case cash can mean that one is going to be fleeced. Hospitals can charge many multiples of what they expect to collect. I’ve had that happen to me and I told them where to go. The price was reduced to the average payment received in one case and completely dropped in the other.”

    But Al, isn’t that the private “competitive” market you seem to keep telling us will solve health care costs?

    By the way it appears you’re uninsured??

  70. Sandra, I don’t want to interpret what the site says. I simply did a quick Google search for the site to find a reasonable number.

    People without insurance are frequently scr-wed. It’s horrid. Cash should be king, but in this case cash can mean that one is going to be fleeced. Hospitals can charge many multiples of what they expect to collect. I’ve had that happen to me and I told them where to go. The price was reduced to the average payment received in one case and completely dropped in the other.

    If you want ball park estimates of what to pay you could consider looking at the Medicare fee table and figure paying 20-30% more. Alternatively I think John’s Hopkins has a specific fee schedule that actually matches what they are paid. (Some sort of agreement?) I have also seen places on the net that can provide estimates of costs.

    Medicaid pays less than Medicare, but that fee schedule depends upon the state.

    I hope I answered your questions.

  71. “I don’t expect you to understand complexities such as how competition lowers prices.”

    Al, I have been on this blog almost since it’s inception and yes my comments are in “black and white”, as many long time posters will attest.

    I have been through countless posts and comments about how to lower costs in health care. What comes up over and over again from simple solution conservatives is “competition” will save us – yet they never seem to recognize (or accept) that health care is not like buying a fridge or a car. If it were we’d have the “solution” at hand. The health care market does not exist in a true competitive environment.

    “Perfectly competitive markets exhibit the following characteristics:

    There is perfect knowledge, with no information failure or time lags. Knowledge is freely available to all participants, which means that risk-taking is minimal and the role of the entrepreneur is limited.

    There are no barriers to entry into or exit out of the market.

    Firms produce homogeneous, identical, units of output that are not branded.

    Each unit of input, such as units of labour, are also homogeneous.

    No single firm can influence the market price, or market conditions. The single firm is said to be a price taker, taking its price from the whole industry.

    There are a very large numbers of firms in the market.

    There is no need for government regulation, except to make markets more competitive.

    There are assumed to be no externalities, that is no external costs or benefits.

    Firms can only make normal profits in the long run, but they can make abnormal profits in the short run.”

    Now you can argue that no present day good or service can meet the above definition, but health care is the furthest from the above and needs a much more complicated management – usually a heavy dose of government regulation. That’s why no other country in the world has chosen the U.S. model (as if we designed it this way).

    Even Taiwan, which had the opportunity to craft a system from scratch chose one with heavy government control.

  72. Al, a couple of questions about the costs listed, in case you have more information. The top 2 items on the list are “insurance deductibles” and “insurance co-pays”. Does that mean the rest of the costs listed are not reimbursable by most payers? Also, I’m assuming these are estimates for people with insurance (because it does mention insurance deductibles and co-pays). Would these costs be different if a person was not insured? How about Medicaid or SSD? Just curious in case you know – I find all these statistics (and discussions about healthcare costs) confusing generally. Whenever I have in the past tried to draw conclusions from these types of reports I’ve found they usually tell only part of the story.

  73. @Bob: “has run up bills of close to $2 million since then, he is 18.”

    Bob, I am glad your nephew got what he needed and I applaud those doctors and the hospital that were able to do the procedure. Your nephew was lucky to live in a country where the procedure could be done.

    Firstly was that the bills or what was paid? I am assuming those bills were for the 15 years including the transplant and whatever follow-up was required. That amounts about $130,000 per years in billing or actual payments for the cost of the transplant and all complications that followed over a period of 15 years.

    The total cost of the liver transplant averages $577,100. Recognizing that there is less elasticity in this type of patient can you tell us what you would like to cut out to make the cost more affordable?


    “When the hospital comes calling for more than $100,000 on one life, the hospital should be told that reimbursement has ceased and the family has no liablilty either.”

    Are you advocating that the hospital go bankrupt?

    I am sorry for your nephew. Obviously he has had complications and that likely made his costs rise dramatically. Do you think he shouldn’t have had the surgery?

  74. Peter1,

    My words and quotes even of major highly respected health care studies speak for themselves and your vulgarities speak for you. I don’t expect you to understand complexities such as how competition lowers prices. Say what you will, your comments are in black and white.

  75. Al, I do have a tendency to use the term ‘bloated’ when I mean ‘huge’.

    My nephew received a liver transplant at age 3 and has run up bills of close to $2 million since then, he is 18.

    Maybe each bill was not bloated, but the total is.

    His parents are bankrupt, the city govt health plan they were on is nearly bankrupt, and the poor kid will likely die in the next year.

    These huge claims drive up insurance costs faster, in my opinion, than the more frequent but much tinier claims for extra tests, contraception, and the other mandates.

    The ACA is going to outlaw any policy that has a maximum benefit like $250,000. My viewpoint was very different. I think people should be able to buy a cheaper policy with a lower max benefit. When the hospital comes calling for more than $100,000 on one life, the hospital should be told that reimbursement has ceased and the family has no liablilty either.

  76. “Last time when I provided facts”

    You provide NO facts, insightful comment or credible links (studies). You do provide platitudes.

  77. Peter1 Should I answer you? Last time when I provided facts that left you without an appropriate response you became frustrated and resorted to insults. Why should I explain to you something you are unwilling to hear and perhaps unable to understand.

    I will answer your questions and provide a six word explanation for the first question and a one word explanation for the second instead of a more detailed explanation. You can go to the books to find out what I mean.

    “Isn’t that the definition of Obamacare?”


    The poor will be crowded out.



  78. “We need to insure those people that can afford insurance. We need to help those that are borderline so they too can be insured with the general population.”

    Isn’t that the definition of Obamacare?

    “Those that remain (and that number is not all that high) may need to be treated differently”


  79. Bob, what you call stubbornness, I call adherence to the facts on the ground and in our own respective ways it appears we both do the same.

    It is true I look at external causes and blame many of them for the high costs, but what I think you might be leaving out when you talk about bloated charges is that more frequently than not bloated charges are caused by market failures. In this case the market failure is predominantly government intervention or dumb intervention since I believe that under the best of circumstances some people that fall through the cracks will need help.

    But before you go any further, you indicate that heart surgery is a bloated cost. We might be able to bring prices down somewhat, but bloated? I can think of a lot of things one might want to refer to as bloated, but that wouldn’t include heart surgery unless you mean things in a different fashion than I interpret. Break down heart surgery into its costs and then show me where it is bloated. Be careful when you evaluate costs. Make sure you are looking at what is paid, not what is billed and look at the median amounts not the outliers.

    ” it is why I look to social insurance solutions.”

    That is where I believe your thinking goes astray. You are confusing involuntary charity with insurance. We need to insure those people that can afford insurance. We need to help those that are borderline so they too can be insured with the general population. Those that remain (and that number is not all that high) may need to be treated differently, but our goal should be to ultimately mainstream them as well.

  80. Al, I like your stubbornness. Like me you are convinced that what we call normal health insurance costs too much.

    I would locate the causes somewhat differently than you — I look at the bloated charges for a bariatric surgery or hip replacement or open heart surgery or transplant, and you look more at the mandates.

    We may both be right.

    Just to clarify one point: until the ACA, the underwriting for individual insurance was in fact just like the underwriting for disability insurance……
    if the applicant had a condition, exclude it or rider it, and if you could not exclude it then reject the applicant. I worked at one point for an insurance company.

    The ACA changes this, but we get much higher premiums as a result.
    This gives me a sense of futility about non-group health insurance, and it is why I look to social insurance solutions.

    Bob Hertz, The Health Care Crusade

  81. Bob, do you believe the desire for disability insurance would ever be the same as that for health insurance? Remember, there is such a thing as workman’s comp. How about home owners insurance? There certainly are more than 2-3% of the population buying that product.

    “I am trying to get you to admit that the country needs more than private insurance can provide.”

    I assume what you are saying is that some people cannot afford the cost of private insurance. That is true. But, then we have to define who that is and why. One of the reasons is that some people are being charged more than their risk, so perhaps they perceive insurance as a tax or a partial tax or even unnecessary. Maybe the insurance isn’t personalized enough due to government regulations and maybe those regulations cost too much. The number of uninsured that truly couldn’t afford health insurance is a lot lower than the number touted. Perhaps we have to look a bit deeper and consider that what we are trying to offer is prepaid care rather than insurance and most people don’t buy the pre-paid type of expensive stuff because it costs to much compared to the value it provides.

    In the end the call for single payer, universal, etc. health insurance has more to with ideology than taking care of people.

  82. I have sold disability insurance, and Al, it operates in a way that would satisfy you.

    If you have a back problem, you cannot buy insurance for a back related disabiity. You can only buy insurance for some random disability like being in a car accident or falling off a ladder.

    Actuarially this is OK. Private insurance does its job.

    But the result is a product that is only purchased by about 2-3% of the American public.

    I am trying to get you to admit that the country needs more than private insurance can provide.

  83. “Of the 11% bump”

    Bob, I would like to see the study and perhaps a bit more. To provide numbers like 11% and 8% immediately tells me that the study is dealing in the abstract and is more likely trying to satisfy an ideology than to provide true knowledge.

    There are 50 states so the number would vary by state. I don’t know where you live, but your wife’s premium might be a lot lower in another state with less mandates. If you have the study let me see it so I can read the methodology and work some numbers.

    The best way to manage these problems is to have a basic plan that one adds or subtracts from so we are all on the same playing field. Insurance needs to be risk adjusted to prevent death spirals. After one sees the costs one can use some type of subsidy to help those in true need.

    By the way insurance is supposed to be purchased in advance. One cannot buy insurance for a house that already burned down, but they can buy it for the part that is left standing.

  84. Peter1 who seems to have a limited ability to express himself like an educated adult says: “You’re an idiot ”

    Are you the typical left winger that throws insults for lack of a good intellectual argument? We see a lot of those around now a days. I made the statement that you should expand your views because you ignorantly lumped classical liberals with ‘right wingers’ and probably everything else that doesn’t meet the collectivist mindset. That means you are ignorant of the world around you and really need a bit of education. Mind you, not schooling, but real education.

    “that’s part of being in a civilized society, not in the jungle.”

    You obviously have no idea of what civilized means. Look at the type of discourse you favor, insults. Along with learning what being civilized really means you ought to learn a bit about economics for it seems you probably are one that is looking for automobile insurance that pays for your gas, tires and brakes.

  85. “We have to pass the bill to find out what’s in it.” Sorry. That wasn’t from a Republican.

  86. “Repeated surveys of the American people show they either do not understand it nor in favor of it.”

    David, Americans like the provisions, such as no pre-exist, but don’t like the mandate – how do you think Americans intend to bring those divergent views together and pay for the benefits they like?

  87. The reason ACA is demonized is that no Republicans voted for it and several democrats had to be bribed. Repeated surveys of the American people show they either do not understand it nor in favor of it. No one voting for it read it I would maintain. The administration’s delay of part of the mandate is in direct violation of Article II Section 3 of the US Constitution. In case Mr. Reich forgot, it says, …”he (the POTUS) shall take Care that the Laws be faithfully executed,…”This law is a disaster and should be defunded without delay.

  88. “Peter, I suggest you expand your views.”

    You’re an idiot Al, and have no conception of “expanded views”.

    Certain mandates are added because they include everyone in the group to lower the price for those that might need them – that’s part of being in a civilized society, not in the jungle.

    Do you think mammograms are a luxury, diabetes supplies, or maybe breast reconstruction, now that seems like it would be less expensive out-of-pocket. Tell me what you would cut and why. Maybe since you are a man you would cut all health mandates for women’s health since you’ll never need them.

    Making them paid out-of-pocket doesn’t make them less expensive (just ask the uninsured), it makes the insurance less.

    Wake up and see the real world Al.

  89. According to the research that I have read, all mandates together add about 11% to the cost of a health insurance policy. This was measured by studying the actual claims paid for those items of coverage.

    Of the 11% bump, 8% was due to maternity and mental health parity.

    So, stripping out all mandates would not solve the insurance cost problem by itself.

    Al, you want the right to buy a ‘true’ catastrophic policy that only covers accidents, injuries, and some unexpected condition.

    And I have no problem with you having access to such a policy.

    But this has never been hard for the insurance industry to provide.

    The challenge is how to cover people who are going to have health costs that are NOT unexpected.

    A private insurance firm cannot offer policies to people who are already diagnosed with a condition. You see this in disability insurance and long-term care insurance all the time.

    If you really need it, they won’t sell it to you.

    Nor can they, unless premiums are raised for everyone across the board.

    I have not sensed from your posts in this string that you really have any solution for those whose costs are expected. Surprise me.

  90. Peter1, considering the fact that every mandate adds to the cost of the desirable action it also adds a greater cost to the premium. If procedure x costs x amount of dollars the total cost will be x + ?%X. Why would you want to pay more for the procedure in your premium then you would in paying for it out of pocket?

    I think your problem is that you might not know the difference between prepaid health care and real health care insurance for unexpected and very large claims that might otherwise be unaffordable or cause undesirable hardship. When you insure your car do you over insure so that your insurer pays for your gas and tires? That would be pure foolishness and it is the same in health care.

    Thus I might not find any of the mandates objectionable, however, there are reasons why some would not normally be covered. They are less expensive paid out of pocket and by including them in the insurance premium they make the insurance premium more expensive so some people drop insurance. If they are expensive mandates then one has to learn why they weren’t included in the normal insurance offering.

    Remember, one could offer a basic policy and then have riders to add or subtract from that policy. That way the insurance is risk based which keeps premiums lower, prevents death spirals and ends up being a more satisfactory way of making sure people are insured.

    Peter, I suggest you expand your views. By limiting them so much to just one type of opinion labeling the rest right wing you have made yourself quite unaware of what really is happening and how various ideas change the nature of health care.

  91. Uwe – thank you. I wish I am as young as you think and as I wish to be despite having two beautiful grandchildren. If things have not been done “right way” – and from your post I assume that we have similar understanding of what is right, it does not mean they have to be done “wrong way”. But you certainly sensed something different in my background – and it is my experience living in the Soviet Union. It has been many blessed years since we became citizens of this wonderful country, but I still remember very well what happens with a society where people rely on “free” stuff from the government rather than on themselves and what happens when a bureaucracy takes control over people instead of serving them as originally intended.

  92. Interesting amount of comments…politics meets technology! If the old Ryan voucher plan had gathered any steam..well same issues dealing with the legacy fed’s COBOL systems…same tech issues and this is what’s hitting Obamacare right now to a degree. Then we have the useless attacks on the delays..why I wrote..”will it blend”…


    HHS is not totally out there though as they awarded a new contingency contract with Serco to provide the bill mail warehouse, the biggest company you have never heard of. By the way the UK, which is where Serco is headquartered in addition to all the other HHS and military contract they have here is being investigated fro fraud over there and no new contracts until the investigation is done.


    The complexities all come from the insurance industry with their complex math models and we don’t have enough sleuths on the government’s side and they get distracted with doing things like running Facebook contests:) Here’s a good example of hospice for profit and being I lost my mother recently I had to explore this and thank goodness I did so I didn’t end up with the subsidiary of United Healthcare taking care of my Mom in her final days. When I looked at their privacy statement looks to me like more data for sale and I guess even when you are dead they still sell your data to “business associates”. Selling insurance and providing hospice…a strange and maybe questionable combination of subsidiaries. By the way do look at the mountains of subsidiary companies there..huge..how do you know who owns what? We have a too big to fail insurance conglomerate in the making here.


    Insurers modeled this the way they want it and a couple are cutting fat hogs from the government with subsidiaries that might even be larger than Tri-Care, like LHI that does medical events and contracts to handle VA disabilities. In view of all the over avenues of revenue and walking away from HHS over to DOD where the big money is at, the company could just say “we don’t need anymore individual policies in California”..it is what it is.

    Too bad the government can’t model or hire some “real sleuths” in data scientists or quants and get the run down on what the other side does as it seems now we are a big panicked and are throwing money around in big numbers to make enrollment succeed. I know it has to be done but next HHS director should have a little tech or IT in their background. I said back in 2009 that the HHS job would morph into a job with about 80% Health IT responsibilities and I think we can see that now. Nothing personal, but is is what it is. AlgoDuping will show you with some videos what modeling is all about and how it works so about time the government both in the financial markets and in healthcare embrace this as there’s the root with math models that suck everyone in and they are not correct or have huge flaws. Flawed mostly for profit. The Quant documentary in the video group makes this very clear.


    In the meantime I’ll wait until the GOP representative for my area decides to do another robo call for his next town hall meeting:)

  93. Boris,

    I assume that you are a young man. Were you not, you would realize that your prescription “cost control first, then universal coverage” is over three decades old. In reality, it means “forget the uninsured.”

    I recall debating a US Senator on that point on the Jim Lehrer show. my suggestion was then that Congress should give up its cozy, tax-payer funded, fully community-rated health insurance and that Members of Congress should be forced to buy coverage in the medically underwritten non-group market until they have managed to enact a decent universal insurance plan. I still think it is a good idea, if only to teach Members something about the real world.

  94. Al, here’s the mandates in NC:

    North Carolina has 24 health insurance benefit mandates.

    According to the Council for Affordable Health Insurance, an insurance industry group that generally advocates against increased mandates, North Carolina has the 18th most mandates in the United States.

    Idaho has the fewest mandates, with seven; while Maryland has the most, at 39. The median was 21 mandates, which Kentucky and Tennessee have.

    Among the most common benefits in North Carolina’s mandates: Mammograms, maternity stays, breast reconstruction, alcoholism, diabetes supplies and emergency services.

    Among the least common: Birthing centers, cleft palate, bone mass measurement, human papilloma virus vaccine, newborn hearing screenings and TMJ disorders.

    North Carolina also requires insurers cover clinical trials, mastectomies, hospital stays after a mastectomy, colorectal cancer screening, cervical cancer screening and contraceptives, among other things.

    Although it’s not yet listed, the General Assembly recently added a 25th benefit mandate: mental health parity.

    What would you like to strip out to “plummet” costs?

  95. “My wife’s policy with a $7,000 deductible has sure as heck stripped out all luxury times.”

    Has it? What are the criteria for a first cataract removal? A second? Does it pay for your PSA? Does it pay for any Hail Mary’s? I could drill deeper and get a lot more oil, but I think you get my point. But wait, what about the mandates your state forces upon insurer’s?

    Get down to basic care without all the external interventions and health care costs will plummet. People don’t even recognize what luxury care is and I am not talking about any reduction in over-all quality or favorable outcomes.

    Some people think ObamaCare is great, but the problem is that it was a compromise that took the worst from the left and the worst from the right and created an Obamination. People are too stuck in their ideologies to be able to see much light or deal with solving the problems that need to be solved. Instead they have a deified a President that spends a ton of money on his vacations and then says we have a fiscal responsibility to reduce veterans care and close the White House to school children. The man sounds like the usual despot of the 20th century.

  96. You raise a good point about luxury items. Arnold Kling’s book on health care makes a distinction between basic care for accidents, injuries, and crippliing diseaes…….versus ‘premium medicine’ which probes for every possible illness even if we do not have it yet.

    But on the assumption that hard cases make good law, let me go back to the example in my own household.

    My wife’s policy with a $7,000 deductible has sure as heck stripped out all luxury tiems. (it does pay $300 for an annual physical.)

    Yet after all this lean and mean, we still have a problem affording the premium.

    I can sense where this is going. At the bottom of my probing is my belief that some part of health insurance should be tied to income.

    People with low incomes should pay less for health insurance, no matter their age or medical history.

    This is why I favor some form of social insurance.

    In its very clumsy way the ACA brings this idea forward.

  97. When we will see health care has a necessity and not a luxury? Every human being should be able to afford health care. Why do so many people resent Obamacare and fight against it? How many addicts who are desperate for help will finally be able to get treatment if they are covered under Obamacare? What about people who are sick and cannot afford insurance and ignore their symptoms until it is too late and then go to the ER and get a 5,000 bill which the tax payers wind up with anyway? Let’s stop fighting Obamacare and allow it to be implemented.

  98. Boy, your knee jerk reaction seems to be unilateral and hyperactive on the left side with no sense of balance. You asked for ways of dealing with the health care dilemma and seem to think only one way exists. That is pretty narrow minded.

    The NCPA is not right wing. It appears to come from the more classical liberal venue. In case you don’t recognize what that is you might want to read a bit of history and discover that our founding fathers relied mostly upon classical liberal values, but that did not mean that they didn’t believe in some government involvement.

    The collectivist values of many that call themselves Liberals today seems to attract those that are attracted to the collectivist nations of the 20th century. The leaders of many of those nations caused the deaths of over 100 million people not due to war, rather to political expediency frequently seen by those that carry the leftist label.

  99. Bob, the ACA will only get us out of the problem of the uninsurable by distorting the market place and making things worse. What seems to work on paper in the Ivory Towers does not work with real people, because they have self interest that dominates collectivist concerns. Additionally it is not hard to isolate those that fall through the cracks by becoming uninsurable and there are ways to prevent that from happening in the first place.

    “high deductible insurance is moderately cheaper than low-deductible insurance. The difference between the two declines with age.”

    Incomes climb with age and we should be putting money away for all things that have to do with retirement. We spent a lot of money on Chinese goods for things Americans bought and didn’t need.

    “sometimes BOTH kinds of insurance are too expensive for Americans.”

    The key is sometimes. If expenditures for health care are too great for all of the American public then we have to reduce what we believe we need. Alternatively we have to let the market place and competition bring prices down. A lot of health care that is paid with pooled funds is a luxury item.

  100. Al, I’m not defensive at all, I’m trying to grasp your shifting sands of reason.

    As for your NCPA link, it’s just a right wing rant site with the usual players.

    “The NCPA joined with scholars at The Heritage Foundation, The Cato Institute, the American Enterprise Institute and the American Action Network to identify what most needs to be repealed and replaced in the Affordable Care Act of 2010 (ObamaCare).”

    If you don’t like how the health system players gang up on patients then just remove government from the mix – something the NCPA would like to see.

  101. Peter1, I don’t understand you. You are too defensive. I quote a passage from a Canadian Supreme Court Judge and suddenly you attribute all sorts of ideas to me. What is your problem?

    Do I believe health care in the US, not Canada, can be better managed if we would rely more on the market place? Yes, but that doesn’t mean I am willing to let those in true need not receive reasonable health care even if I have to pay more. Since you asked for a suggestion and a complete plan would be quite lengthy (no where near the length of the ACA) I would first end the reliance upon employer sponsored health care by equalizing or getting rid of the tax deduction. You can find more complete plans at the ncpa.org website.

    As far as my negative comments about the ACA that everyone gangs up on one side with financial interests that differ from the patients interest is a fact and has been reasonably proven. ACO’s for all intents and purposes have the same incentives as HMO’s. Here is what the distinguished Ware Study said about HMO care:

    “Conclusions.–During the study period, elderly and poor chronically ill patients had worse physical health outcomes in HMOs than in FFS systems”

    Based upon similar incentives the same will happen to those in ACO’s.

  102. Al, you raise a very good point about how the applicants for individual insurance are in fact looked at with actuarial suspicion by private insurance companies.

    Some would say that the ACA will get us out of that vicious cycle, by moving toward a national risk pool. We’ll see. The ACA alone can do nothing about insurer pricing.

    As for the issue of whether insurance is expensive………

    all I will admit to is that high deductible insurance is moderately cheaper than low-deductible insurance. The difference between the two declines with age.

    The real point is that sometimes BOTH kinds of insurance are too expensive for Americans.

  103. Al, you’re not making much sense. You extoll the Quebec court decision that rules on the tyranny of “monopoly” yet you want to be able to choose between employer pay or government pay – two “monopolies”.

    Then you write: “The government, big business, hospitals, insurers, physicians and people that like to control your life whether you like it or not are all on one side because their profits depend upon one another.”

    Tell us how you will get away from that and be free to afford health care?

    You want to do away with 3rd party pay – do you favor a cash based system?

  104. “I think you are relying on the ciiche that high deductible insurance is cheap”

    Bob, absolutely not! High deductible insurance is less expensive and has been demonstrated recently to also save considerable amounts of money by not starting a work up that should have been held off. Those work-ups have considerable costs attached. These are two distinct mechanisms of reducing health care costs and premiums and they have a very large effect.

    One has to also remember that those that do not have employer sponsored insurance are suspected by the insurers to have health problems and thus their premiums are higher than they should be because the insurer’s perceive a greater risk. One also has to think about what state one resides in since different states create unbelievable differences in cost. There are methods to reduce the risk of elevated premiums based upon new diseases. Example policies where the deductible only has to be paid once for a 36 month period. There are also methods of reducing the need to pay a deductible every year once a person is sick enough to meet the high deductible.

    The ACA doesn’t solve the cost or access issues. It simply makes matters worse eventually causing health care quality to decline as the politicians ‘widgettize’ both patients and diseases.

  105. Al, I think you are relying on the ciiche that high deductible insurance is cheap, and so why should people not buy the high deductible coverage and save the difference?

    High deductible insurance is cheap if you are a younger male.

    It also feels cheap if you have a six figure income.

    My wife is age 61. She has a Blue Cross policy with a $7000 deductible that still costs $450 a month.

    (before i turned age 65, I had a similar policy.)

    We have a modest income. How the heck is she supposed to save any money for her predictable expenses, when $450 is going right out the door the first of every month?

    Our situation is repeated in millions of households in the US. Even a high deductible policy eats up a great deal of discretionary income.

    Now…..the proponents of high deductible plans in John Goodman’s camp do have an answer for this problem. The answer is that you must save money when you are young, which is when high deductible plans are indeed cheap.

    Which takes us back full circle to my statement that HSA’s must be mandatory to work at all.

  106. AMA =/= physician. I have yet, in 20 years, to meet a PCP who wants to control the life or finances of their patient. Most that I know want the patient to have more responsibility and thus more control over their own healthcare.

  107. “Quebec never restricted”

    Peter1, no one said that Canada restricted Canadians from crossing the border. I merely quoted a Supreme Court Justices opinion and from that quote you are making all sorts of explanations that do not pertain to this quote. I am happy that Canadian wait times are improving, but that is the problem of the people of Canada and they know better than I what their needs are. Even Robert Reich doesn’t suggest that as a foreigner he tell Canadians what to do.

    The quote: “This virtual monopoly, on the evidence, results in delays in treatment that adversely affect the citizen’s security of the person. Where a law adversely affects life, liberty or security of the person, it must conform to the principles of fundamental justice. This law, in our view, fails to do so”

  108. Sandra, of course some people run into high costs. That is why one carries insurance. The reason the premiums are so high is because of near first dollar coverage and the reason why health care costs are so high is because of third party payer (employer).

    Those like Robert Reich aren’t as interested in health care as they are in controlling people’s lives. If they cared more about our health we would not be having this discussion. Take note of the competing forces seen with ACO’s that are part of the ACA.

    The government, big business, hospitals, insurers, physicians and people that like to control your life whether you like it or not are all on one side because their profits depend upon one another. On the other side is the patient, sick, without financial resources and left all alone out in the cold.

  109. Forcing people to save into an HSA won’t help when you open up the entitlement coffers and let people ride free. Every deli window has an EBT sign in the window. They accept it, they have forms for you to sign up for it and they help you fill them out. How about looking for help wanted signs,filling out those forms and helping fill those out. The abuses are too may, and we are getting fed up. We paid 100k for my daughter to go to school alongside those who went for free. My daughter graduated, because she knew she had student debt to pay back. Many of those that went free, dropped out. Its all backwards!

  110. You may think this is rare and most don’t have this risk, but people sometimes do run into very large healthcare costs and do not have a way to pay for it long-term. A catastrophic vascular event or neurological event or trauma or cancer that leads to long-term catastrophic healthcare costs, especially if you have to leave your job temporarily or permanently is something you can’t possibly save for. And if you have a child with a catastrophic illness – I have heard social workers advise parents to divorce so a mother qualifies for Medicaid. And I’ve seen farmers lose their farms because they had an MI. The thing with insurance is you have to continue to pay the premiums. Many serious illnesses leave you without a job – and therefore without insurance and unable to even pay for COBRA. I don’t think ACA really takes care of all these issues – either healthcare (and insurance has to be much less expensive, or there needs to be a way for average and low income people to access healthcare if they really need it.

  111. Al, Quebec never restricted a person from seeking treatment in the U.S. or anywhere else. Wait times in Canada have been improving. I wonder how long the wait time is for an uninsured person here needing elective surgery?

    No one gets a bill in Canada, access is selective, after all it,s free. Yes, people jump the que, but if they wanted to pay themselves they could go anywhere.

    You might want to read this:

  112. I think that savings have to be mandatory, like Singapore’s.

    Otherwise those who do save will be eventually be taxed to pay for those who do not save.

    I have said for a long time that all modern health systems rely on some form of financial coercion.

    The question is where the coercion takes place:

    a. taxes (like Canada)

    b. individual mandate (like Switzerland)

    c. Employer and indiividual mandate (Germany/France)

    d. being hounded by creditors if you cannot pay your medical bills (USA)

    e. Mandatory HSA’s

    It is more productive to compare the forms of coercion, rather than set up a contrast of freedom vs the state.

  113. Peter1, no one said anything of the kind. I quoted the statement because it explained the danger of monopoly in very explicit terms “results in delays in treatment that adversely affect the citizen’s security of the person.”. Perhaps the Canadian temperament is more forgiving than mine and is not as impatient so waiting on line is no big thing. Alternatively for those that don’t want to wait too long can cross the border and pay cash. No big deal. Canada is different than the US and requires different solutions, but Canada just like all western nations has to deal with the sustainability issue.

    By the way people jump the queues all the time in Canada.

  114. Bob, that is what insurance is for, high cost unexpected care. Also remember that except for a very few most are putting away money for years to pay off these one time expenses.

  115. I was not referring to care within the system. See Chaoulli v Quebec. Take note of what was written by one Supreme Court Justice.

    “This virtual monopoly, on the evidence, results in delays in treatment that
    adversely affect the citizen’s security of the person. Where a law adversely
    affects life, liberty or security of the person, it must conform to the principles of fundamental justice. This law, in our view, fails to do so”

  116. The whole health care debate leading to total meltdown over what is a very trivial change to our system just exposed that our Constitutional system–intended to prevent foreign dictatorship in an agrarian society– is totally outdated. Why it wasnt changed after the Civil War is beyond me, but to make sensible policy requires some kind of parliamentary unified system. Fat chance of getting that, while the 0.1% runs the country and no one gives a toss about the bottom 50%.

    And so we end up with the ACA being the best we can get

  117. Apples to apples ours rates are going down 30% unless Peter Lee is hoodwinking me. And the two largest carriers (the 2 Blues) aren’t leaving, Aetna and United are leaving the individual and small group market as they are too SMALL in California to match the discounts that the Blues were able to get. And it’s about time someone took on California providers who have been living high on the hog for more than a decade now.

  118. Another problem with obamacare is that there was no legislation for legal limits. Physicians and big Pharma have to pay through the nose because everybody sues, and lawyers are always on the prowl. It costs you nothing to sue, but millions to defend. Baddrug.com, and all the malpractice insurance gets passed along to us. Lets get lawsuit limits in place, but Obama is a lawyer, and they never think like the rest of us. This ACA has many good initiatives, I’m in healthcare IT, so I know. But until you stop the lawyers from their feeding frenzy, its going to get worse. ACA has us sharing medical charts electronically. Can you see the lawsuits start flying when physician start relying on each other? More and deeper pockets.

  119. You need to look at the “trial” period that wiped out funding in the first 3 months. They have no idea what this will cost, nor who will pay for it. Generation Y is opting out, and taking the $90 penalty. All the sick are enrolling in droves and those already on assistance, just got more. Meanwhile the middle class which has almost become extinct (qualifying us for minority status) are getting jacked up by 42% . This is unsustainable!

  120. What happens in those other countries is that people know that they have to take care of their health as they are not given much sympathy if they smoke, consume alcohol, etc. They know intensive care is not as available as in the U.S., so they work a lot harder at taking care of things themselves. And the UK is investing in creative ways to help people help themselves – something that we seem not as able to do systematically, I think. I was very impressed with this effort by the NHS:


    They were at the most recent Datapalooza event in DC last month. What a wonderful project undertaken by very caring and professional individuals.

  121. Single payer systems do have global budgets, but that doesn’t mean that high cost care isn’t available. It means they are careful where they spend their money and how much they pay for products and services. Take, for example, Michael Seres of the UK. He received a small bowel transplant at a UK hospital and follow up care that has not bankrupted him. Would he be able to carry on his productive life if he had the same medical condition in the U.S.? I don’t know, but I’ve seen diseases such as his cause people here to claim disability because they are unable to find employment that has generous enough health insurance to afford to work, even though they still could. And the UK pays roughly half of what we do in the U.S. The ACA does not even begin to fix this. You can’t have an open ended system where both insurance companies and provider organizations get paid for whatever they demand, which is essentially what we have now.

  122. Cynthia, I think you have touched on something that few among us are willing to consider or to advocate. The ACA is a major political accomplishment for the Obama administration, but who are the winners and who are the losers?

    So far, insurance companies are the biggest winners; they will need to staff up just to handle the demand. Close behind them are drug manufacturers, who continue charge American consumers triple what they charge those in Mexico and Canada.

    Who are the losers? Healthcare providers, who will see payments slashed as regulatory oversight becomes even more burdensome, will suffer and some will go out of practice. And healthcare consumers are the biggest losers because the demand for healthcare services will increase while availablility and quality goes down.

    The sad reality is that the US is without a healthcare system. What we have is a hodgepodge of competing interests, regulated by elected officials who are bought and paid for by those who are being regulated.

    Perhaps a Constitutional Amendment prohibiting Americans from being denied healthcare services could set the political and judicial processes in motion to get Uncle Sam to work for us instead of the highest bidder.

  123. Personal choice makes great sense for discretionary care in a doctor’s office or outpatient setting.

    Not sure how it can work for care that costs over $20,000. It would take years for most Americans to have $20,000 in an HSA. Without assistance, many would never have a balance like that.

    I am open to proposals, though.

  124. “Which would you rather have:”

    Bob, how nice of you to provide me only two choices, being killed with a gun or being killed with a knife when there are so many other choices. 🙂

    I would prefer the choice of running away and in health care means that third party payer is ended and my choice is substituted for the choice of my employer or the government. We haven’t tried that in decades so perhaps you wish to add that choice to your list.

  125. No, I do not think any country can afford insurance that covers every treatment at retail prices.

    You are totally correct — globally budgeted institutions tend to focus on procedures that have the most interest and create the best reputations for the senior doctors or senior faculty.

    That leaves an interesting dilemma.

    Which would you rather have:

    a state-funded hospital that is free to the user, but if you have a boring disease you might be given quite cursory treatment……..

    or an American system where insurance companies pay so much for many surgeries that you can top notch treatments with no waiting lists.

    But you have to pay a lot for the insurance, and even more if you do not have insurance.

    Not sure of the answer myself!

  126. @Bob: “The single payer ideology does relieve the individual from bad choices.”

    No it doesn’t. It opens the gate to further politicizing medical care. Look at where federal grants go and note the inequality of the money that seems in many cases to be based upon political rather than scientific needs.

    Single payer really doesn’t provide what many think. All it does is control prices and ration care. That is not very much different from an insurance company that sets the payment and determines that something is not medically necessary.

    Single payer does not provide for true competition, reduces innovation, etc. It also prevents patients that are willing to pay for better care from getting that care. It leads to cases like Chaoulli v. Quebec where the Supreme Court intervened claiming “Access to a waiting list is not access to health care,”

    It seems what you are asking for is universal insurance.

  127. Not everyone lives in California. I live on the East Coast and pretty much what I am hearing from everyone is that their premiums have already gone up 50-100% and their employers are telling them it’s only going to continue to go up. So how is that beneficial to anyone who currently has insurance? I understand that people who were not previously “insurable” are finally going to be able to get insurance and that is great for them, but the cost across the board is high for everyone.
    Add to that the fact that employers are having a really hard time trying to figure out what exactly they are required to do (b/c the bill was so well written and all) that they are wasting hundreds of hours of man time on this.
    Are there issues with the insurance system in the US? Absolutely. But you will not convince me that the ACA, as it is now, is the answer. Anytime the government decides to take control of something and force it down the publics throat, it never ends well.

  128. The single payer ideology does relieve the individual from bad choices.
    Single payer systems would put the large academic hospitals onto global budgets, and there would be no insurance denials.

    In this system, the hospital might not have enough money for a proton beam device to cure prostate cancer. The system as a whole might refuse to buy a cancer drug that costs $100,000 a year.

    So some individuals would not get the best health care money can buy. I am OK with that, but I see massive resistance in public opinion not to mention the courts.

  129. @ Bob: “But it is a thorny issue, and neither the ACA nor its opponents tend to deal with it straight on.”

    Many alternative solutions have been proposed and you know that. Example: John Goodman’s solution along with many others including those that advocate single payer. You just may not like the solutions, but they exist. No solution will or can be perfect so you cannot use the excuse of imperfection to deny the existence of valid alternatives.

  130. Pat, yes you could go on, but just because one is looking for a market solution does not mean the government cannot provide subsidies to those truly in need, but those subsidies need to be realistic. We don’t need to provide Viagra to a relatively young man that already has children that he is not paying for.

    Thus, even with HSA’s poor people can survive. Remember they have to pay for housing, clothing, food, etc. so they are getting money somewhere. If the government provides a subsidy that can make the HSA or any insurance plan more affordable. If not there is Medicaid. Remember, there are studies demonstrating that HSA’s work in the not so affluent population as well.

    In the end poor and rich, every taxpayer is paying for our bloated health care system. What lowers prices? Competition. Take note how many of the poor own cell phones, computers, air conditioners, refrigerators and all household amenities. That money comes from somewhere. I don’t begrudge a poor person’s benefits as long as the money goes for necessities, but it appears we have lost sight of reality.

    If you are a responsible working person and pay taxes think of how much money would be left in your account if normal competitive forces ruled the health care market. All costs would be lower including your premiums that are likely paid in part by your employer. Part of that money could be yours.

  131. Peter 1, I think they can say they are non partisan because they are supporting an economic theory, free markets and classical liberalism, not a particular political party.

  132. OK.

    I just don’t know why anyone would expect another to read through the entire bill. I actually read almost the entire HR bill before the Senate version. Many of the important points of the bill were near unintelligible and like the Senate bill that passed (ACA) only a skeleton designating important decisions to those appointed by the executive branch.

    Passage of such a poorly written bill (no matter one’s philosophy) demonstrates that our legislature is no longer able to deal with the important social issues our nation has. They have become a self serving branch of the government and that includes both parties even though the blame for this bill rests squarely on the Obama administration and the Democratic legislators.

    As far as your idea of universal care, that is an idea not a program. In reality we already have universal care on a definitional basis.

  133. Al, in this current congress how likely are any of these plans you mention to make it into some sort of law that provides a reasonable guarantee to affordable health care? HSAs may be great if you can afford to contribute to them. For someone making $34,000 a year (an income that Mr Koch seems to think puts you in the top 1% or earners) How can anyone possibly put aside enough to pay for even routine exams and tests much less a more major procedure and provide for a family, save for retirement, college education, etc? What about preexisting condition exclusions by insurance providers? I could go on…

  134. Thanks for your continued thoughtful responses Bob. I like that you are issue and problem/solution oriented, not an ideologue like some here.

  135. Aurthur, ‘access’ to healthcare available to all Americans? Well, I guess if you count emergency room visits access to healthcare, you are right. But access to AFFORDABLE healthcare is NOT available to ALL Americans. Even what you might consider middle class Americans have been driven to bankruptcy by medical costs.

  136. Aurthur made the comment that the policies in the exchanges will have limited medical networks.

    This raises a very interesting point. It hits on an issue that has been a sticking point in health reform for over 20 years.

    A limited network will tend to exclude the most expensive hospitals — i.e. the UCLA Medical Center, Mt Sinai, Mayo Clinic, Sloan Kettering cancer centers, etc. Such a network may also not cover the most expensive specialists in any community.

    This can save a lot of money in premiums. As a former actuarial student, let me tell you that it takes very few $250,000 claims to drive up premiums for any small or medium sized group.

    But inevitably there will be one or two patients who have a rare cancer or rare blood disease who would clearly benefit from one of the top medical centers and from a blockbuster drug.

    But their policy gives out, and then you have bake sales and bankruptcies and early deaths, and maybe John Grisham or Sixty Minutes covers the case too. This happened on a regular basis with some breast cancer treatments in the 1990’s.

    The ‘debate’ is between the greatest good for the greatest number, versus making sure that every insured gets the best care that money can buy.

    In other words, if 999 persons benefit from lower insurance costs, and one person suffers in some way, is this acceptable?

    I think that if you asked Canadians, they would say “darned right it is acceptable.”

    Clark Havighurst of Duke has written a lot about this problem. If a person makes a free and conscious choice to limit their insurance, but then finds out they made the wrong choice, what as a society do we do?

    I think that the absolutist answer — cover everything, no policy limits, no mini-med policies, any willing provider, no exclusions — is not the right answer fiscally.

    But it is a thorny issue, and neither the ACA nor its opponents tend to deal with it straight on.

    Bob Hertz, The Health Care Crusade

  137. Al, I don’t support this bill or it’s meager and failing attempt (so far) to bring universal health care to America.

  138. Bob, how can they state they are “non-partisan”?

    The National Center for Policy Analysis (NCPA) is a nonprofit, nonpartisan public policy research organization, established in 1983. Our goal is to develop and promote private, free-market alternatives to government regulation and control, solving problems by relying on the strength of the competitive, entrepreneurial
    private sector.

  139. Kate, surprise, our lofty representatives usually NEVER read the bill. In this money for hire system they hardly have time to because they’re dialing for dollars.

    You want better, well read legislation, you change the bribery system of government.

  140. Pat, there are loads of plans out their and loads of methods to manage the problem. With picking the ACA we just happen to have picked on one of the worst plans possible. I say possible because there is always something worse, but I just can’t think of anything at the moment.

    If you want an idea of what else is out there or the idea for another plan check out John Goodman’s plan at the NCPA. He is the father of HSA’s probably the only major program that actually worked as stated.


  141. If by “essentially” you mean rates can vary by 20% for RAF, and 60 to 100% based on rating area (which has recently been gerrymandered into 19 areas from 9 so as to fool certain younger less likely to be covered Californians into thinking the rates are now lower for them), and you ignore current loads for very small groups and you pay no attention to the number, quality or make up of the providers in the networks associated with the plans, then OK.

    Believe it or not, I no longer live in California. I do believe the two largest carriers are opting out and many carriers opting in are shrinking their networks for the products in the exchanges.

    With the gerrymandering of rate areas that constitute your community, the outlawing of a 20% discount for medical conditions, and the rate compression on age factors, I remain curious to see what happens to your group’s rates when you compare today’s apples to next year’s apples. Thanks.

  142. These may not qualify as credible sources (HuffPO, Heritage, and particularly CMS), but when facts don’t matter, does it really matter if they are facts?



    ACA may indeed be the most perfectly not perfect legislation ever.

    p.s. All American have access to health care now and before this bill passed. Thanks.

  143. More cows to be milked. If they really wanted care they would have found a way.

    Healthcare is too expensive because there is too much money paid out without considering the value of the purchase.

  144. There are a lot of assertions being made here, e.g. “overestimated enrollment by 650%, underestimated costs by 122%, ” with no attribution to a credible source. Then there’s people making comments like: “Anyone who thinks ACA is perfect as it stands is in for some big surprises if it goes into effect as is.” which is ridiculous. Of course detractors have been screaming it’s imperfect, but even supporters said it was when first passed and that modifications would need to be made. That was not some smoking gun of incompetence, but reality. * NO* bill is perfect when first passed. As one person here asked…where is your alternative plan to provide healthcare at reasonable cost to all Americans?

  145. Well funnily enough CURRENTLY in California, groups between 2-50 buy into what’s essentially a community rated pool. So where Arthur’s low risk, young employer group is buying with rates that are going to go up 30% when Covered California’s rates are lower than my group of young, community rated employees currently receives, I await to hear with interest. Especially as Covered California has been aggressively getting plans to reduce pricing in a way the small employee pool cannot.

    And unless you were a proponent of a single payer globally budgeted system, or another that effectively got employers out of buying heath care and turned it over to the tax payer, criticizing the ACA is just intellectually dishonest. It’s all that could be got through our ridiculous system of government and even this minimal change barely passed and only because there were amazing 60 Democrats in the Senate. And that included such wild-eyed lefties as Baucus and Lieberman.

    So while I don’t think the ACA is a failure, I do think America’s system of government is.

  146. Mr. Holt. Thank you for pointing out I am right and you were wrong. However, you cannot buy into Covered California now…172 days 18 hrs 13 mins

    Until New Coverage Begins for Millions of Californians

    Health care coverage begins January 1, 2014

    Unless most of your employees are older, sicker, in a higher risk industry, and in a higher cost area of California then the average, your insurance will not be 30% less.

    If your employees are younger, healthier, in a low risk industry, in a low cost area of California, your rates will increase 30 to 100% since The Act outlaws private carriers from offering your employees discounts for these favorable factors.

    Yes, I do know more about buying insurance (health) for a small business than you do. I do not consider you a schmuck, necessarily. However, if it turns out your costs going through the exchange when the plans are available, is 30% higher than your current arrangement with Healthnet, then I believe you should also admit The Act is a failure. I am curious to hear. Thanks.

  147. Well folks, we are to the point where rubber meets the road with Obamacare. Clearly, it CAN’T be implemented unless the sun, the moon, and every single star line up AND unemployment is under 5%. The largest retailers and restaurants have pledged to cut employee hours to below 30 – and they can easily do that – because millions are lined up to take part-time jobs.

    Here’s the thing with healthcare: it costs more than almost anything, it’s unavoidable, and no one wants to pay for it. We stumbled into employer-funded healthcare after WWII, which works well enough, but because it’s voluntary, it leaves out millions. Obamacare tries to fix that with a number of mandates, but that makes employers try to dodge it using loopholes. Single payer deals with this problem, but good luck getting that through Congress.

  148. “So far the clear beneficiaries of the ACA have included uninsurable children under age 26, high-risk insured’s in states which had no high-risk pools and seniors nearing the donut hole in Medicare Part D.”

    Do you consider all the insurance carriers deciding to cease offering individual policies to anyone under 18 a benefit to these children?

    Do you consider the PCIP beneficial when the administration overestimated enrollment by 650%, underestimated costs by 122%, attempted to hide the program from the public, and ultimately shut the program down to new enrollees half way through the process?

    Reich is a shill without courage to debate. Thanks.

  149. I read the entire bill with amendments. At the very least, ACA needs a huge number of corrections. Anyone who thinks ACA is perfect as it stands is in for some big surprises if it goes into effect as is.

  150. To be fair, Arthur is right. Because I can now buy into the Covered California Exchange my company (with under 50 employees) can purchase insurance at about 30% less than we currently pay. How that hurts me, I’m not sure.

    Of course when I said the ACA didn’t apply to under 50 employee businesses I meant that the employer mandate didn’t apply. Still I’m sure Arthur knows way more about buying insurance for a small business than I do. I’m just a schmuck who writes Healthnet a check for my company’s insurance that has become 30% larger EVERY YEAR for the past 5 years.

    But surely the ACA will make that worse.

    And yes doing anything else than paying for health insurance out of generalized income tax is stupid, but welcome to America….

    And the chances of me being silent are low…perhaps Arthur will identify himself and his vast experience and expertise in the matter?

  151. Matthew-I did not say small business with less than 50 employees, I said SMALLER business. Meaning none national corporations, local companies that may be bigger than 50 employees but still not have the cash flow to withstand all the requirements of the ACA. My husbands job requires that he interact with 10-15 different companies each day over an area of 3 different states. The negative impact on these companies is real. It’s not exaggerated, it’s not hysterics, it’s not political. The owners are from both political parties, and they are upset and worried.

  152. Mr. Holt, Please stop embarrassing yourself. If you are unaware of The Act’s affects on under 50 employee groups, you should be silent. Thanks.

  153. No, I have not read the entire bill, although I have read huge chunks of it. Despite the fact that it’s not my job to read it. The fact of the matter is, our elected officials failed. They openly admit that they have no idea what the majority of the bill says.

  154. What type of logical response is this? Kate didn’t vote on the bill, so why should she have to read it in its entirety? It is up to you, the supporter of the bill, the one that is imposing his ideas onto others to justify its existence.

  155. As the ACA doesn’t apply to small businesses under 50 employees, it’s pretty hard to see who Kate is talking about. Or are national fast food chains small businesses?

    And BTW it’s only the stupidity of our political system that makes such a trivial change to our insurance system, as in the ACA, impacting well under 10% of the population a massive “revolutionary” change

  156. Many of the Republicans who would vote for repeal have perfectly secure group coverage themselves, either through Medicare or through employment.

    When Social Security and Medicare became law, many of the first beneficiaries were very poor. One had to truly have a heart of stone to oppose these initial programs, and the average voter was somewhat repulsed by the Republican opposition.

    With Social Security and Medicare, the government came in with fresh money where there was no money, and no reliable insurance for seniors.
    These programs started sending out money less than six months after they passed.

    The ACA relies a lot more on ‘moving money around’ inside the health care
    system, and the ACA also relies on private insurers a great deal.

    This makes it harder for the Democrats to point to a large voting bloc as
    “beneficiaries of the ACA.” So far the clear beneficiaries of the ACA have included uninsurable children under age 26, high-risk insureds in states which had no high-risk pools, and seniors nearing the donut hole in Medicare Part D.

    This is not a voting bloc. Given the slow implementation of the ACA, done in large part to mask deficit spending, it is hard to rally a large group of beneficiaries right noiw. Prof Reich is a good ideological supporter, but there is no substitute for live voters who like their benefits.

  157. ” The ACA was pushed through by people who are supposed to represent the people and they have no clue what is even in the bill.”

    Have you read the bill Kate?

  158. Change is hard, especially when it the change lowers your income. Why should we expect most doctors, hospitals, pharmaceutical companies and the like to be on board. The status quo has made all but the primary care provider quite satisfied.

  159. As a family physician I have already seen many of the benefits of Obamacare. Medicare wellness exams have brought in many fixed-income seniors who had not been getting preventative services prior because they could not afford the deductible and copay costs of even an office visit. Slightly better reimbursement for primary care services may, I hope, allow us to better recruit primary care providers by offering better compensation. I’ve seen no negative impacts so far, and look forward to more benefits to Americans as the rest of teh bill comes in 2014. I hope this is not the first nail in Obamacare’s coffin.

  160. Here are my “two cents” without going deep into the details: I think we all agree that the cost of healthcare in this country is unreasonably high. This realization alone prompts to take actions to reduce this cost FIRST (how – is another topic) and ONLY THEN to provide (one way or another) all the people with the insurances. Most of ACA provisions only declare but in fact do not provide the cost reductions, moreover, increased bureaucracy as always leads to cost increases.

  161. O. K. How would all of you replace the Obamacare???? What are your ideas of a new plan??? How about Ryan’s voucher plan for all. You can buy your insurance in any state AND FOLLOW THE HEALTH INSURANCE LAWS OF THESE STATES. There will be no pre-existing condition and there will be a cap on lifetime payments. These insurances will only take those who are quite healthy. Is that your way of thinking????

  162. “The longer the Affordable Care Act is delayed, the more time Republicans have to demonize it before average Americans receive its benefits and understand its importance”

    Don’t you mean the longer it’s delayed the more chance there is of the truth about how horrible the ACA really is, has of coming to light? The ACA was pushed through by people who are supposed to represent the people and they have no clue what is even in the bill. They pretended that this was what was best for America, but they really were just spewing the party line talking points. The reality is the ACA is already having crushing affects on smaller business, who are scrambling to try and figure out whether to let people go or let their business go under. Doctors are choosing to either retire or stop taking insurance all together. The writing is on the wall and the Administrations “reprieve” is nothing but a thinly veiled attempt to convince people that they care about small business. Those of us who aren’t drinking the koolaide can see it clear as day.

  163. “…has more to do with the Republicans’ incessant efforts to bulldoze the law.”

    Please, you are an educated man. The ACA was pushed through knowing that almost no one knew what was in it and the fact that the bill was half baked and not ready for passage. Among other things it passed only because of promises never to be realized and special waivers.

    Now after this unripe bill was passed you wish to blame someone else. That represents grade school thinking where one refuses to take responsibility and is compelled to always blame someone else.

  164. Prediction #1

    Repeal becomes THE story early next year. I am guessing much of the maneuvering around this has to do with making sure any effort does not succeed. The administration is electing to look stupid now (unavoidable, when you think about it) rather than suffer a resounding defeat next year …