Robert Laszewski (and Ezra Klein) on where Obamacare stands right now

by on January 9, 2014 at 11:15 am in Current Affairs, Economics, Law, Medicine | Permalink

This is a very good interview, read the whole thing, here is one bit from Laszewski:

There’s a big misconception that this is about young people. That’s baloney. It’s about healthy people. A healthy 20-year-old might only pay a $100 premium. You want healthy 40 and 50-year-olds. The big problem right now is really total enrollment. We only have about 10 percent of the uninsured in here. Insurers think you need more like 70 percent of a pool of people to sign up.

Here is another:

I have an interesting answer for that. I think the mandate is almost worthless because the word is getting around that they can’t really collect it. And by year three, it’s really a lot of money. I think there’ll be real pressure to just get rid of it. I don’t think you can force people to buy this insurance. If they don’t want it there’ll be a political groundswell to get rid of it. So in my mind the individual mandate is kind of irrelevant to this.

And another:

…I do have a concern that people are looking at these plans and not finding value. Some people are looking at paying 10 percent of their income for plans with huge deductibles, and then you have politics of Obamacare and the bad press of the launch and if you put all those things in a bag and mix them up, I am really concerned that the uninsured who are healthy are not finding Obamacare the value they hoped it will be. That’s the real risk for Obamacare.

Read the whole thing, for Ezra’s responses too.

1 CPV January 9, 2014 at 11:34 am

Right, they didn’t design the system for the people they need to pay for it, which is a small slice of the country to start with. Not smart. It’s a large, complex tax on the middle/upper middle class individual payer market. Question: why should that segment of society alone pay for the uninsured?

2 Z January 9, 2014 at 11:50 am

Because it is cheaper than the alternatives. I’m not saying it is the answer, but it is one possible answer. The other is the benefits that accrue to the charitable. People will spend a lot of money to feel good. They will spend even more of someone else’s money to feel better.

3 mulp January 9, 2014 at 1:08 pm

No, it is because conservatives will not call for the free market creative destruction required to make free market health care work for the uninsured who are uninsured by either choice, or more often be the nature of economic survival of the fittest and random creative destruction of the unlucky weak selected for destruction.

Ronald Reagan signed the free lunch get out of creative destruction jail card which was a part of the massive omnibus bill that no one read or understood: EMTALA.

Free market health care requires death panels to declare a person bankrupt and subject to liquidation to recover sunk costs and eliminate liabilities.

Euthanasia and sale of body parts if uninsured and devoid of funds to pay for medical care is obviously the market solution required.

All we need are real free market advocates to make this case in Congress so the required laws allow the Federal technocrats to implement creative destruction in regard to medical care costs (bankruptcy judges).

4 RJB January 9, 2014 at 1:24 pm

Poe’s law, libertarian version.

5 Cliff January 9, 2014 at 2:20 pm

No, it’s pretty obvious satyre

6 JWatts January 9, 2014 at 2:43 pm

“Poe’s law”

It certainly reads like a parody of what a foaming at the mouth Liberal thinks about Conservatives’ motives.

7 lxm January 9, 2014 at 3:14 pm


Ok, what are real conservative motives? What are your motives?

How do conservatives solve pricing problems like this:

Good luck!

8 dead serious January 9, 2014 at 3:22 pm

JWatts is a Reagan groupie. Trickle Down Healthcare should work out well.

9 JWatts January 9, 2014 at 4:57 pm

“Ok, what are real conservative motives? What are your motives?”

To state the basics:

If a system provides healthcare that 70% of the population considers good to excellent, then any major changes as a baseline should increase that percentage, not decrease it. The first goal of any major overhaul should be to make the system distinctly better. If you can’t make it better then you leave it alone.

10 msgkings January 9, 2014 at 5:15 pm


Leaving it alone not really an option, due to demographics. We pay too much now, but if nothing changes we quite literally won’t be able to afford it in 10-15 years.

11 JWatts January 9, 2014 at 6:40 pm

“Leaving it alone not really an option, due to demographics. We pay too much now, but if nothing changes we quite literally won’t be able to afford it in 10-15 years”

I see your point and agree with it, but since Obamacare mandated higher benefits than many existing plans, it’s going in exactly the wrong direction.

12 lxm January 9, 2014 at 6:45 pm


I see you decided to skip the pricing issue.

I have no idea why you think 70% were satisfied with their health care. Employees may be satisfied but I can guarantee you that their employers who were paying for it were not.

Bottom line: your position is that conservatives saw no reason to change existing health care.


13 JWatts January 9, 2014 at 6:59 pm

“I have no idea why you think 70% were satisfied with their health care.”

69% of Americans rate their personal healthcare coverage as excellent or good

“Bottom line: your position is that conservatives saw no reason to change existing health care.”

Bottom line: Liberal’s made the health care system worse.

14 msgkings January 9, 2014 at 8:04 pm


I agree trying to extend coverage and make more plans include more items no doubt isn’t helpful purely on a cost basis. But Obamacare is more than just the exchanges. There’s a fair amount of ‘bending the cost curve’ incentives and ideas in it, and there’s some evidence that some of that is having a beneficial effect on costs.

Obamacare is a mess but any path from where we were to something that works is going to be messy, especially when one side of the debate doesn’t want to play.

15 prior_approval January 10, 2014 at 1:17 am

‘I see your point and agree with it, but since Obamacare mandated higher benefits than many existing plans, it’s going in exactly the wrong direction.’

Well, considering that essentially every other advanced society actually provides more benefits for a cost that it at least a third cheaper (that being the current difference between America at number 1 in cost, and whoever is the current number2 – which fluctuates, actually, as other systems react to circumstances), it seems as if the problem is not in the ‘benefits,’ but in the actual restructuring of a health care system. And the benefits provided by such a system – such as no concerns about being bankrupted by medical costs, nor a need to worry about remaining employed due to employer provided insurance – are undeniable. Though some people consider them to be socialist, of course.

There are plenty of other models to choose from – only America’s is unique, at this point.

16 NateO January 10, 2014 at 2:05 am

This is obvious satire, but let’s not forget that creative destruction is also a supply-side issue. Lobbyists of hospitals have made it almost impossible for an entrepreneur to open a new one that can compete on price, and lobbyists for doctors have made it almost impossible for anyone other than an 8-year lab-rat to give out meds for an ear infection.

Back to demand though, people with chronic conditions spend the most on health and should be encouraged to shop on the margin for the best care. We will never have affordable healthcare if the insurance companies don’t get out of the way and let people be consumers of healthcare, not insurance.

17 brad January 9, 2014 at 3:01 pm

That’s not quite right. That portion of the funding sticks out because it is usual, but the subsidies and the medicaid expansion both paid out of general tax revenue involve larger sums.

18 Lord January 10, 2014 at 1:47 am

I agree. It is not about young or old or healthy or ill at all. The poor are subsidized by the government, not the young or healthy or rich except through taxes.

19 Z January 9, 2014 at 11:47 am

I’ve said for a while that ObamaCare was the fulfillment of prophecy rather than public policy. Seeing guys like Ezra Klein go through the stages described in “When Prophecy Fails” confirms it. There’s a reason why we keep seeing the same polices tried over and over, despite failing over and over. The true believer will always find a way to internalize dis-confirmation.

20 Becky Hargrove January 9, 2014 at 12:22 pm

“There’s a reason why we keep seeing the same policies tried over and over, despite failing over and over.”

Yes, because plenty of rational people such as yourself will insist that any options outside the mainstream are worthy of fiction contests.

21 Joe January 9, 2014 at 1:02 pm

Hear that Z? It’s all your fault.

22 Z January 9, 2014 at 1:03 pm

It is predictable. Now that the prophecy has failed, the search for causes is on and surely they will find plenty of bogeymen on the other side of the wall to blame for it.

23 Z January 9, 2014 at 1:02 pm

In your haste to caste aspersions against the heretic, you have failed to make any sense whatsoever. Perhaps you should ask the orderly for another dose and then come back with a proper reply.

24 Becky Hargrove January 9, 2014 at 2:08 pm
25 Z January 9, 2014 at 3:36 pm

This has nothing to do with me or my post.

26 mulp January 9, 2014 at 1:13 pm

Are you arguing that market solutions can’t work for health care, so the only solution is a government run single payer system as advocated by progressives from all parties?

The issue is how can you have a market solution to health care when individual get to opt out of the market place and simply demand, using the law President Reagan signed, free medical care when they need it and can’t pay for it by their own choices.

27 Becky Hargrove January 9, 2014 at 1:55 pm

No. I’m arguing for a true marketplace in health care (and other services) where all who are willing to provide whatever services others will accept, are free to arbitrage their skills and knowledge.

28 Cliff January 9, 2014 at 2:22 pm

Because they can’t actually do that. No one gets health care without a bill

29 Matt2 January 9, 2014 at 3:38 pm

“Getting a bill” is not the same as “paying for.”

30 prior_approval January 10, 2014 at 1:56 am

I haven’t gotten a bill for any medical service for more than 20 years. True, I don’t live in the U.S.

Strangely enough, the amount of my income that goes to pay for health insurance is less than what other family members (employed by a federal three letter agency, a leading public school system in the DC region, a major credit card provider, and one of the world’s largest pharmaceutical companies) pay for theirs in the U.S. In large part being that in Germany, at when using the non-private Krankenkassen, everyone in a family is covered through a single ‘policy.’

Admittedly, this comes with its price – Germany’s system is a third cheaper than the American one. And the waiting times are brutal – I walked five minutes to the doctor to have him look at something I’d noticed, and it took him over 15 minutes to see me, without an appointment. The dentist (about a 3 minute walk) was the same – my appointment was at 7:15am, and I’m sure that I wasn’t in the examination room until at least 7:30am. Of course, considering there are two other doctors and one other dentist in this town of 6,000, if I was all that dissatisfied, it would be easy to compare. To use American terms, they are all in-network, and none need to accept you as a patient first.

It’s really amazing what being forced to experience un-American health care systems does to a person’s perspective (French health care, the couple of times I’ve experienced it, is very similar in terms of waiting and being treated, even if the models they use are quite different in many ways).

This is one the things that makes this discussion so sad, in its way – Americans have no idea how bad their health care system is except for a fairly limited minority, and the rest of the world only has an inkling of the reality, meaning that most people outside the U.S. assume that America’s system bears at least some resemblance to their own. Which is false. Much like the broad American consensus that their health care system is better.

31 Marie January 9, 2014 at 6:48 pm

“by their own choices. . . .”

I think there are tons of people out there that make sure they stay free of assets and without insurance so that they can spend their time in the ER when they get sick. It’s the good life.

Cliff is right, anyone who goes to the ER gets a bill. If you have assets that can be legally taken, they will be. If you don’t, you have bigger problems than whether or not President Obama’s folks are mad at you for not signing on to ACA.

32 prior_approval January 10, 2014 at 2:00 am

‘I think there are tons of people out there that make sure they stay free of assets and without insurance so that they can spend their time in the ER when they get sick. It’s the good life.’

This is another example of Poe’s law, right?

Because anyone seriously suggesting this is American reality would just be a cartoon of a conservative/libertarian, right?

33 Marie January 10, 2014 at 10:07 am

It was sarcasm based on the assertion that it’s common for people to be unable to pay medical bills “by their own choices”, which I don’t believe was suggested by a conservative/libertarian.

It’s funny to me how demonized poor people in ERs are by liberals these days. They have become such evil doers, and so common, our whole health care system needs to be entirely revamped because there are so many deadbeat poor people using the ERs as their personal day spas.

Granting that the quote I referenced was supposed to be Poe-ish, I still see that argument everywhere on the left, we need ACA because of the horrible problem with ER bills.

34 Ted Craig January 9, 2014 at 11:56 am

Off to topic but somewhat connected: Is Tyler going to comment on Klein’s latest career move?

35 JWatts January 9, 2014 at 2:46 pm

Is it a career move or career suicide?

36 Ted Craig January 9, 2014 at 4:13 pm

We’ll see. I’m not a Klein fan, but I could see him gathering together a pretty strong line-up if he started his own site.

37 Albigensian January 9, 2014 at 12:07 pm

” I don’t think you can force people to buy this insurance. If they don’t want it there’ll be a political groundswell to get rid of it. So in my mind the individual mandate is kind of irrelevant to this.”

BUT the system depends on implicit redistribution- that those who are poor insurance risks will be subsidized by those who are not. Without the individual mandate, how do you get this to work?

38 Ryan Vann January 9, 2014 at 12:24 pm

Broaden the pool, lower the individual taxes, aka expand Medicare. Not a difficult problem to solve

39 Yancey Ward January 9, 2014 at 12:31 pm

Just one little problem- Democrats could have done this between January 2009- January 2011, but did not. Until you understand why they didn’t do that, then you will keep repeating this “solution”.

40 mulp January 9, 2014 at 1:40 pm

Because that would be free market private sector health care, and Democrats only believe in socialism run by the government agencies of Wellpoint Anthem, Aetna, HCA, …

Thank god Obama kept his government hands off my private sector Medicare.

Especially by removing the government encroachment on Medicare in the government takeover of Medicare Advantage by those government health care agencies.

41 brad January 9, 2014 at 3:05 pm

One big reason — selfish old people want to keep Medicare exclusive. They worry quality will be diluted if the unwashed young people get to join the party.

“Keep your government hands off my Medicare!”

42 T. Shaw January 9, 2014 at 12:33 pm

I similarly solved my problem.

I ensconced the remains of that latest whiskey bottle in my granddaughter’s sippy cup.

Another not difficuklt problem solved.

My advice to you people: drink heavily.

43 msgkings January 9, 2014 at 1:10 pm

You have a granddaughter? So you’re surely using that evil socialist Medicare, right?

44 Marie January 10, 2014 at 3:48 pm

I believe this is one of the worst effects of socialized medicine.

The people who are forced to use it are berated for using it if they are critical of it in any way.

It’s bizarre, it’s like dressing down the inmates of Andersonville if they complain about the food — hey, you’re eating that food! What gall you have for suggesting it could be better quality, and how dare you suggest everyone should not be in camp with you, you must be selfishly hoarding all that good camp time for yourself.

In addition to the cruelty and injustice of it, it is a huge bar to any kind of real reform and allows programs to become more and more inefficient, stultified, dysfunctional, and corrupted — if the people who know the best about a program are not allowed to say how it can be improved or if it should end, you get a mess.

45 msgkings January 10, 2014 at 5:20 pm

The point of my type of snark here is not berating those folks, it’s to point out that many people who rail against the whole idea of any kind of social insurance often benefit from those arrangements and refuse to see how perhaps they have some positive attributes. T Shaw is pretty snarky too, I realize in his true heart of hearts he probably (at least I hope so) acknowledges that there are some ways in which a nation can collectively design programs to help out the old or sick or poor. Medicare is one of those, and while it needs lots of work it’s overall a pretty good program. And TShaw knows it.

46 Ad Nauseum January 9, 2014 at 12:07 pm

I hate to sound like one of those Fox News junkies, but we will probably see a push for “universal healthcare” as a response to low coverage of healthy people in this system. And that may have been part of an overall strategy to ease us into a universal healthcare system. It was not politically feasible before, but now that we’ve made the transition to the PPACA and we’re seeing some of the flaws (expected flaws I should add). The next logical step will be A.) enact a universal healthcare system, or B.) scrap much of the PPACA.

My bet is that option A will have more political clout in the coming years. I’m hoping for a two tier system if I’m right.

47 msgkings January 9, 2014 at 12:17 pm

If this is the path to universal catastrophic/major expense coverage with everything else privately financed that would be a pretty good outcome. If employer-based coverage is taken out of the mix that would be even better. A lot of path dependence to overcome though.

48 Dan Weber January 9, 2014 at 7:40 pm

Honestly I would have loved that. The really big problem is that you’re going to have to face the concept of “this procedure can save (and/or improve) your life, but we’ve decided it’s not worth it. Pay for it yourself if you can.”

I believe this policy is inevitable, but it will still be an incredibly hard sell for Americans.

49 Yancey Ward January 9, 2014 at 12:33 pm

The failure of PPACA does not strengthen the hand of the party favoring A)- it weakens it.

50 mulp January 9, 2014 at 1:46 pm

So, when conservatives attack Obamacare for forcing people to buy insurance from for profit corporations and use the for profit corporate providers that the for profit insurers pick to maximize their profits, while calling for keeping Obama’s government hands off Medicare which places zero restrictions on patient choices of providers, that isn’t a call to go toward Medicare, but a call to go toward profits being the primary determination of whether you get any medical care??

51 Ad Nauseum January 9, 2014 at 1:59 pm

……call this nitpicking if you want but:
1.) Not all insurers are for profit (eg. Blue Shield)
2.) Not all providers are for profit
3.) “while calling for keeping Obama’s government hands off Medicare” represents a very small amount of the overall opposition, let alone population. They were just given high media coverage because the for profit media needed to make ratings, and laughing at someone you feel superior to is an easy way to do that.
4.) For profit insurance companies were not very profitable, and still are not very profitable. (3% margins on average)

Given those observations, I don’t see how it’s profits were ever the primary determination of whether you get any medical care. Costs were the primary determination.

52 Jan January 9, 2014 at 2:20 pm

Negative. It is a very different approach.

53 Jan January 9, 2014 at 2:20 pm

You and everyone else knows why they didn’t do that.

54 JWatts January 9, 2014 at 2:51 pm

“The failure of PPACA does not strengthen the hand of the party favoring A)- it weakens it.”

Absolutely. The Left has spent too much political clout on Obamacare at this point. The refrain that, “This time we can fix healthcare”, is going to ring pretty hollow.

55 dearieme January 9, 2014 at 4:21 pm

The notion that the US federal government could run a health care system well enough to be comparable to France, Singapore, and so on is laughable.

56 Dan Weber January 9, 2014 at 7:42 pm

As Kathleen Sebelius said, they didn’t try to replace everyone’s health care because 80% of non-retirees already have it through their employer, and they don’t want that messed with.

57 JonFraz January 9, 2014 at 6:15 pm

Except that the ACA is a one-way street. There’s no viable path back to the status quo ante– which would also be fought tooth and nail by big money players in the health and insurance agencies which have spent good money on the ACA. The ACA is certainly not set in stone nor do I believe it will lead to single payer, but any reform will preserve the major and many minor changes.

58 Marie January 9, 2014 at 6:52 pm

This is right.
Plus, all players are now too weary to scratch and start again, I’d think. I know personally, I’m sick to death of it. And economically, having something in place you can count on probably is getting to be pretty important, isn’t it? Surely any conservative politicians who want to shake things up again are going to be sitting down at dinners with a lot of businessmen who hate ACA but hate the idea of another upheaval even more.

59 T. Shaw January 9, 2014 at 12:38 pm

Then, the progressives will have solved the health care crisis of 2006.

In 2006, 13% to 20% of respondents were unhappy with their health care arrangements.

In 2016, 13% of repsondents will be happy . . .

My advice to you people: don’t get sick.

60 mulp January 9, 2014 at 1:55 pm

Given 85% of people had other people paying for their health care arrangements and 15% were paying for their own, I’d say that close to 100% were unhappy to be forced to pay for their own health care arrangements, and close to 100% were happy that someone else was paying for their health care arrangements.

Just out of curiosity, were you paying for your own health care arrangements in 2006, and were you happy that you were paying higher prices than those who were lucky to have someone else pay less than you did?

I know I was very very unhappy to be paying $9000 a year for $5000 deductible insurance when 5 months difference in employment would have resulted in employer retirement coverage that was comprehensive costing the retirement fund about $5000. But I was in the free market and denied access to the unfree market of group insurance.

61 Paul January 9, 2014 at 1:15 pm

I think most people see this as a disruptive government intervention for not much of an improvement in coverage. It’ll be a hard sell to convince the 85% who already have employer based insurance that what we really need to do is scrap the entire system and start over. As unhappy as some people are with health care in America, I don’t think we hate it so much that individuals who otherwise feel secure would be willing guinea pigs in a brand new system. There would be too much uncertainty.

Unless you could guarantee that health costs + taxes would go down for 50% + 1 vote of the country, single payer won’t find wide support, especially after the uninterrupted negative press the ACA has been getting.

And I say this as someone who wants the ACA to succeed, is enjoying some of its benefits and think single-payer is the way to go!

62 msgkings January 9, 2014 at 1:23 pm

Sadly, +1. There’s your path dependence in detail.
Employer-based coverage has become a real albatross, and all due to WWII

63 Ed January 9, 2014 at 1:44 pm

The way out may be a make-work jobs program where government contractors “employ” people at whatever unemployment insurance pays plus health insurance, and maybe some regulation of existing employer health insurance plans to put in cost controls and portability.

Single payer advocates have also called for just gradually expanding the existing government provided healthcare programs so that they cover more people, and I have never heard a really good argument against this.

64 msgkings January 9, 2014 at 1:56 pm

Medicare for all does cover everyone, obviously, but it doesn’t help the looming cost catastrophe as the baby boomers get older. That’s the main problem we have as a nation, a demographic one. The promises to pay we currently offer those over 65 isn’t affordable in about 10-15 years, plain and simple.

65 mulp January 9, 2014 at 3:09 pm

Employer based health insurance began prior to WWII in Texas, started by hospitals looking to fund people using hospitals more.

You are thinking of HMOs which were started by California employers because workers were failing to show up for work reliably, claiming they were sick. But government contractors had government contracts to fill but had most of the best workers going into the military so they needed to hire the workers who were sickly and unfit, or caregivers. Employer health benefits were put in place for the same reason employer worker training was – it increased worker productivity. Only government contractors could afford the health benefits during the war years, but government contractors also had demands for labor that outstripped the supply of healthy workers.

If you think employer health benefits was used to compete for scarce labor, then the non-government contractors should have been the dominant source of employer health benefits: farmers, food and entertainment businesses, luxury goods industries like tailored clothing suppliers. The government contractors being priority segments of the economy would have won exemptions from wage controls if they couldn’t attract enough job applicants, so only if health benefits increased productivity would a government contractor like IBM, GM, Ford, GE, Boeing, et al find it justified reducing profits paying for frills that had nothing to do with productivity.

66 Brian Donohue January 9, 2014 at 2:07 pm

Yes, two-tier system. But how to get there from here?

67 Ed January 9, 2014 at 12:48 pm

Some political site made the interesting, and fairly accurate point, that “Obamacare” is essentially “Hillarycare”. Its pretty much the same system the Clintons tried to foist on the country in 1993, and that Hillary Clinton campaign for, against Obama’s opposition on key points such as the individual mandate, in 2008.

Some people, including commentators on this blog, have traced the origins of the plan to a Heritage foundation plan conceived in response to the 1993 initiative, and implemented with Mit Romney’s signature in Massachussetts. While I think this is an important part of the heritage, this is not as germane to the point I am going to try to make.

A health care plan substantially similar to the ACA collapsed legislatively in 1994, and the Democrats were turned out of Congress in elections that year. The Democratic Congress that enacted the ACA was turned out by the voters in the next election. Primary voters in both parties in 2008 refused to nominate either Clinton or Romney, and in the Democratic primaries health care was actually a major issue. There is a contrasting data point in the re-election of both Bill Clinton and Obama, but this is weakened by Obama’s opponent being Romney.

So I don’t know how you can make predictions about the future of this scheme. The American political elite seems determined to inflict this on the American population, despite it being obviously unpopular, and maybe not even workable in a practical sense. I’m trying to avoid commenting on the various alternatives, I just don’t see the elites suddenly giving up on something they’ve wanted for over twenty years over some detail such as it doesn’t work.

68 Jay January 9, 2014 at 2:28 pm

“Some people, including commentators on this blog, have traced the origins of the plan to a Heritage foundation plan conceived in response to the 1993 initiative, and implemented with Mit Romney’s signature in Massachussetts”

The ACA/Mass plan and the Herritage plan are very different beasts with only the mandate being the common theme. Am I wrong?

69 Ad Nauseum January 9, 2014 at 2:50 pm

You’re not wrong at all. Both were also rejected by a majority of conservatives at the national level too, but ACA proponents will never admit that.

70 mulp January 9, 2014 at 3:40 pm

“Hillarycare”, the Clinton proposal from the White House, not the Democratic plan from Congress, replaced the entire non-government health insurance system with one independent of employers. Wages would be taxed at 7.9%, about the rate of cost of the employer health benefits at the time relative to total wages, and that plus premiums from workers would have gone to regional funds that then supervised and paid benefit managers that paid for the type of plan chosen by the individual for themself and family.

Obamacare is like the 1993 Republican plan led by Chafee:

“In November, 1993, Sen. John Chafee, R-R.I., introduced what was considered to be one of the main Republican health overhaul proposals: “A bill to provide comprehensive reform of the health care system of the United States.”

“Titled the “Health Equity and Access Reform Today Act of 1993,” it had 21 co-sponsors, including two Democrats (Sens. Boren and Kerrey). The bill, which was not debated or voted upon, was an alternative to President Bill Clinton’s plan.

Here is a summary of the 1993 bill:

Title I: Basic Reforms to Expand Access to Health Insurance Coverage and to Ensure Universal Coverage – Subtitle A: Universal Access – Provides access to health insurance coverage under a qualified health plan for every citizen and lawful permanent resident of the United States.

(Sec. 1003) Establishes a program under which persons with low incomes (and who are not eligible for Medicaid) will receive vouchers to buy insurance through purchasing groups.

(Sec. 1004) Requires each employer to make available, either directly, through a purchasing group, or otherwise, enrollment in a qualified health plan to each eligible employee.

Subtitle B: Qualified General Access Plan in the Small Employer and Individual Marketplace- Requires the National Association of Insurance Commissioners to develop specific standards to implement requirements concerning: (1) guaranteed eligibility, availability, and renewability of health insurance coverage; (2) nondiscrimination based on health status; (3) benefits offered; (4) insurer financial solvency; (5) enrollment process; (6) premium rating limitations; (7) risk adjustment; and (8) consumer protection.

(Sec. 1119) Requires each qualified general access plan to: (1) establish and maintain a quality assurance program and a mediation procedures program; and (2) contain assurances of service to designated underserved areas.

(Sec. 1141) Provides for the formation of purchasing groups by individuals and small employers.
Subtitle F: Universal Coverage – Requires each citizen or lawful permanent resident to be covered under a qualified health plan or equivalent health care program by January 1, 2005. Provides an exception for any individual who is opposed for religious reasons to health plan coverage, including those who rely on healing using spiritual means through prayer alone.
(Sec. 6137) Provides for phased-in elimination of Medicare disproportionate share hospital payments.

(Sec. 6138) Directs the Secretary to discontinue hospital reimbursements for costs relating to the recovery of bad debts.

71 ummm January 9, 2014 at 1:03 pm

When the GOP regains control of the senate and exec branch there will be no effort to repeal obamacare because they will be bought off and general inertia of the political process. This is good for healthcare stocks which is why I;m long the XLV etf. Obamacare a gift to investors

72 msgkings January 9, 2014 at 1:23 pm

Here is the complete list of posters here who care about your portfolio:

73 dead serious January 9, 2014 at 3:34 pm


74 John B. Chilton January 9, 2014 at 1:32 pm
75 JWatts January 9, 2014 at 2:59 pm

Ezra Klein makes some excellent points.

76 msgkings January 9, 2014 at 4:34 pm

A commenter on that thread shared a link to another blogger who made even more excellent points. But they are kind of depressing, because they basically show that there are a great number of things that make health care cost far more in the US than elsewhere, and far more than it ‘should’. One bit in particular was illuminating, about how all countries fall pretty squarely on a line with health care spending per capita rising very predictably with GDP per capita: wealthier countries spend more on health care, and in a pretty predictable relationship. But then the US is a big outlier, with a huge excess of spending above where its GDP per capita would predict it to be.

It’s not just defensive medicine, or doctor income, or drug prices…it’s all of those and more. Hence the solution is extremely difficult.

77 ummm January 9, 2014 at 5:38 pm

end of life care. Americans spend a lot of $ to prolong life by a few months

78 msgkings January 9, 2014 at 8:17 pm

That’s in there too, definitely. Death panels are actually going to be required.

79 Andrewl January 9, 2014 at 11:31 pm

Look at it two ways:
1) you’re near end of life and you are sitting on a huge pile of money: what use is that only to you dead? Spend spend spend, just one more day.

2) you have access to someone else’s money: spend spend spend – you can scold me when I’m dead!

80 Marian Kechlibar January 10, 2014 at 6:11 am

Andrew, I am quite sure that, in point 1), a lot of people will consciously choose to die sooner and leave the estate to their children, undepleted by futile care.

Not a few of them are actually quite willing to put a bullet through their head to speed the dying process up. A lot of gun suicides in the USA are older guys with fatal diagnosis.

81 AndrewL January 10, 2014 at 12:52 pm


1) You’re talking about people on their death bed. I’m talking about people in their 70’s spending their fortunes to beat the cancer by a few months, or even years. Just because doctor gives you x months to live, there’s a good chance doctor is wrong. whats that extra time worth to you and your family? is the average family so greedy they’d rather take the cash, than some more time with their loved one?

2) What about the portion of older guys who do not want to speed up the dying process? doesn’t count? are the gun suicides a huge proportion over those who want to live a little longer?

82 msgkings January 10, 2014 at 5:22 pm

My point is if you have money and want to spend it all keeping yourself ‘alive’, that’s your business. The taxpayer will have to impose limits on how much Federal money can be spent on that kind of thing.

83 Dan Weber January 9, 2014 at 7:48 pm

“Single payer” is something that liberals mindlessly pursue and conservatively mindlessly rally against. Neither would recognize it if it treated them for being bit in the ass.

84 Slocum January 9, 2014 at 3:30 pm

Whether or not the mandate stays or goes, expect that the people for whom the exchanges are a lousy deal (younger, healthy people with incomes too high for subsidies) will, by hook or crook, find *some* way to avoid them. They will switch to jobs that offer insurance, or they’ll join medical sharing ministries, or they’ll incorporate and offer themselves employer-based coverage — possibly via new plans that enable even small employers to self-insure. The potential risk of self-insuring can be minimized by adding ‘stop-loss’ plans. And the exchanges provide a catastrophic back-stop as well–because it’s always possible to switch to an exchange plan during the next open-enrollment period — or even sooner if you have (or create) a ‘major life event’. Almost certainly, small businesses that employ young, healthy well-paid workers will start switching to self-insurance plans rather than subject themselves to the Obamacare coverage mandates and age-rating restrictions.

85 JWatts January 9, 2014 at 5:04 pm

“Almost certainly, small businesses that employ young, healthy well-paid workers will start switching to self-insurance plans rather than subject themselves to the Obamacare coverage mandates and age-rating restrictions.”

At the very least you’ll see medium businesses start going over to self-insurance plans with a catastrophic insurance backstop. I’m not as sure that small businesses will feel the need to make any changes.

86 JonFraz January 9, 2014 at 6:26 pm

Many mid-sized business already self-insure. However the most expensive part of health insurance is usually the major med (catastrophic) coverage. Routine expenses are chump change– and with respectable deductibles the plan doesn’t even pay those– I have a $500 deductible (for medical– Rx and dental are separate plans) and even with asthma I have never hit that sum in claims. It’s the five digit and six digit claims that drive up health care premiums.

87 Dan Lavatan January 9, 2014 at 11:06 pm

This isn’t true at all. Reinsurance and stop loss premiums are a few hundred a year. Even the ACA reinsurance program costs less than $70/year for coverage between 45k and 250k.

88 Lord January 10, 2014 at 2:07 am

There is quite a difference between business and individual policies. A $5k policy with a $6k deductible is hardly cheap but fits most peoples idea of catastrophic coverage.

89 jonfraz January 10, 2014 at 3:40 pm

I think you need to reread what I wrote. Are you seriously claiming, that chronic and severe illness is not the major driver of health care costs? This has been pretty well settled for a while.
To be sure, an individual who is young and in good health will not be charged exorbitant rates for reinsurance (a term I think is more accurate than “catastrophic” which conjures up apocalyptic images– “Major med” can also be used and often is). However when we talking about group plans then the reinsurance component becomes a lot more significant. I mentioned in another comment below that a former employer who self-insured saw their reinsurance rates explode when several employees had expensive health events (and the more people in the plan the more likely that is to happen), forcing them back into the regular insurance market.

90 JonFraz January 9, 2014 at 6:22 pm

In your scenario the young people are still paying into the system, even if not via the exchanges: their money goes to the same corporations that sell exchange policies and hence supports the system.

Also, employer group health plans are already community rated and always have been: everyone in the group is charged the same premium regardless of age or health status (the group as a whole is rated by its demographics and claims experience). The ACA does not affect this, and so does not create an incentive for employers to dump the employee health plan. Something else also to remember about workplace health benefits: the people who run the companies are covered by them too, and often these people are older with more complex health histories. A group rated health plan lets them obtain insurance more cheaply than they could on the individual market, which is another reason companies not in extremis rarely drop health insurance benefits.

91 Dan Lavatan January 9, 2014 at 11:16 pm

You don’t seem to understand the concept – they would not pay anything to commercial insurers. With self-insured plans there is no premium. They would just deduct health expenses from revenues (or just pay cash in the case of individuals). While community rating is not an issue, ACA preventative medicine rules may motivate some employers to drop coverage.

92 jonfraz January 10, 2014 at 3:32 pm

Yes, there is a premium: self-insured plans are paired with reinsurance (AKA “catastrophic insurance”) from a commercial source and they will charge a group-rated premium. I worked for a small company (c 100 employees) that tried to go this route, but unfortunately several high dollar illnesses among employees and dependents sent the reinsurance rate sky-high after the first year; they ended up going with regular insurance (from Aetna) instead which was actually cheaper.
By the way, I’ve worked in this field in the past and I know my away around it in some detail.
The “preventative medicine” mandate amounts to one office visit per year: that’s about $80-$100 per employee (and dependent) per year– hardly a ruinous expense. It can be defrayed by deducting it from what’s available for salary increases at comp time.

* Ball-park figure based on what an OV costs at my current physician, in-network rates.

93 Dan Lavatan January 9, 2014 at 11:22 pm

Good to see more people are catch on to this. Note that individuals need not incorporate, it is possible to insure under ERISA as a sole proprietor. You need not create a major life event, you can just end the plan after 18 months and be HIPAA-eligible. Since there is no reporting, it would be impossible to prove you aren’t HIPAA-eligible in any event.

94 Machin Shin January 9, 2014 at 10:18 pm

As a single 25 year old, the cheapest plan I could find would add over 10% to my monthly budget.

The plan now is to ignore the mandate. 🙁

95 prior_approval January 10, 2014 at 4:53 am

Wow – so you would have to pay more than I do in the socialist hell of Germany. Without dental, I assume. And with a likely deductible. And probably with all sorts of other restrictions that Germans can’t even imagine (there is no way to translate the concept ‘in-network,’ for example – here, essentially you just go to a doctor or dentist, hand over your card, and get treated).

America – proud owner of the world’s most profitable health care system. And for some, that is the only consideration that counts when also calling it the world’s best.

96 jonfraz January 10, 2014 at 3:20 pm

Are all German physicians required by law to accept patients from every health fund? In know that in other countries (e.g., the UK) there are physicians who do not accept public plan patients.

97 Zach January 10, 2014 at 1:51 am

Reading that interview reminded me of that scene in Back to the Future where Marty McFly’s family photo shows how everything is going to go wrong in the future.

If you could send this interview back in time to 2009, there’s no way Obamacare would have passed.

98 prior_approval January 10, 2014 at 4:49 am

You’re right, of course. Instead, we would have chosen one of any number of other more effective ways to provide health care. Perhaps ironically, the people most opposed ACA would be even more opposed to choosing one of those other proven models.

Which is why they weren’t even under realistic consideration.

99 jon January 10, 2014 at 8:39 am

One should be careful in accepting what Laszweski says. While he is experienced, some of his statements suggest he has axes to grind. Somewhere example, in earlier interviews he derided the CMS head as a nurse with public policy experience, somehow neglecting her many years as a hospital executive. Even if she has botched the rollout, his description of her background can generously be described as misleading.

If you look closely at what he says, you will see contradictions. For example he complains that the mandated benefits cost too much, citing no data or information on which benefits add too much cost. He later complains that the desires of consumers was not considered and those would be coverage for office visits, lab tests, plus catastrophic coverage. Isn’t that what the high deductibles plus preventive care benefits of existing plans amount to? Oh you want routine sick calls covered? Then it is not catastrophic insurance anymore and the price goes up.

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