by Tyler Cowen
on January 6, 2016 at 2:25 am
in Current Affairs, Economics, Law, Medicine
During the election season Democrats can’t admit Obamacare is broken and Republicans can’t admit it won’t be repealed.
An excellent post from Robert Laszewski, read the whole thing.
“Obamacare is broken” is an assessment of current reality, while “Obamacare won’t be repealed” is a prediction. These assertions are different in kind.
The sense of “Obamacare is broken” is predictive. Do try to keep up.
While there is certainly prediction about how the brokenness is going to continue to unfold, the article very much paints a picture of a system that is currently broken based on current evidence.
Do you understand English? I bet you are among the 23% of Americans polled that want the next President to repeat Obama’s massively failed policies.
Y’all are gonna be mad like in 2012 when the Republican loses.
You’ve got a party elite that’s pro-immigration because it’s pro-business and extremely careful about saying anything that offends anybody, and a party base that’s pretty anti-immigration. Trump walked in and blew that whole thing up. It’s not clear it’s recoverable in the calendar year.
But Obamacare is a sideshow in all this.
I won’t be at all surprised if the Republican loses. However, the Trump phenomenon that seems like a huge story now will disappear once he fizzles in the actual voting. No one is going to remember this stuff in the general.
The ACA is not broken, unless “broken” is a synonym for “not working perfectly”
Yes – it is strange that a program that continues to reduce the uninsured rate is called ‘broken.’ ‘Needs some tinkering after ideas were put in practice’ is the accurate assessment. But also something that can’t be done until either the Republican fever breaks or the Dems take back the House.
It’s the medicaid expansion that did the heavy lifting for adding on insured.
The ACA pretty much made people lives hell, added to the cost of insurance, got them kicked already working plans, got people reductions in working hours, ect.
Why does every PPACA proponent forget some of those people didn’t want insurance?
“Obamacare is broken” is an assessment of policy merit. “Obamacare won’t be repealed” is an assessment of political environment. Saying that Obamacare’s supporters may be able to muster enough political maneuvers (Presidential veto, Senate filibuster, etc.) to prevent its repeal in spite of its failure as policy is hardly a ringing endoresement of it.
One way out of this stalemate would be to effectively gut Obamacare in substance and change it to the consumer and market-based health insurance favored by Republican policy wonks, while still calling it Obamacare to allow for Democratic face saving. “Repeal and replace” in substance, but “tweak and make better” in name. Democrats would probably go along with that since they seem to place a high value on symbolism (the Paris climate agreement, for example). Republicans might not go for that though due to their mix of smart policy wonks combined with culture warrior grass roots activists. It would depend on whether they care more about getting the policy they want or “winning” the political battle.
‘One way out of this stalemate would be to effectively gut Obamacare in substance and change it to the consumer and market-based health insurance favored by Republican policy wonks’
Why bother? The U.S. could just adopt one of the numerous models of a successful health care system, while saving at least a third in costs.
However, not a single one of those equally effective and at least a third cheaper health care systems uses the model apparently favored by Republicans.
“Why bother? The U.S. could just adopt one of the numerous models of a successful health care system, while saving at least a third in costs.”
Seems unlikely, considering that Medicare and Medicaid in the US adopt those models, and have the same higher US costs. If it were so easy to do so, wouldn’t Medicare and Medicaid have lower costs, instead of having comparable costs? Instead we’re continually told that attempts to constrain Medicare and Medicaid costs are unrealistic and beset by fraud.
You can’t reduce the costs of health care. The public will not stand for it. Those other systems are cheaper because they were introduced earlier. But they are more expensive than what they replaced. The British thought that the NHS would save money. It didn’t. It was massively more expensive than they thought from the moment they set it up.
It is obvious really – the public is used to a certain level of medical provision. If you make that provision free, they are not going to use less.
“Those other systems are cheaper because they were introduced earlier. But they are more expensive than what they replaced.”
What have it replaced in, say, the UK and Japan?
What did those systems replace in UK and Japan (or Germany or France)?
This is basically true, but there are certainly ways that you can reduce future increases in spending–especially compared to the trajectory that the US was on–while still improving the quality of care and not denying necessary services.
Jan, I’m not sure about that. The US started at a higher cost level, but grows at the same rate as the rest of the world.
Every level of our health care system costs more than in other countries.
In the US a nurse earns an average wage of $70,000. In Germany it’s $47K. (all figures adjusted for purchasing power parity – http://www.insidermonkey.com/blog/15-highest-paying-countries-for-nurses-367431/)
There are 3.1 million registered nurses in the United States (http://kff.org/other/state-indicator/total-registered-nurses/).
So the excess wages of American nurses alone add at least $70 billion/year to health care costs. Not a single penny of that will be saved by moving to a national health care system.
The same story is true for doctors. American primary care physicians earn twice the salary of PCPs in France, for example. Assuming 200,000 American PCPs earning $100K/year more than their French counterparts, that adds $20 billion/year to our health care costs. None of that can be clawed back without a massive fight.
It gets worse when you look at the specialists. American surgeons earn several hundred thousand dollars a year more than French or German surgeons. You don’t think they’d be willing to set aside a couple percentage points of that to buy TV spots attacking candidates who threaten their livelihoods?
Cutting health care costs means cutting the salaries of something like 10-15% of the American workforce, many of whom are currently near the top of the ladder and have significant public sympathy and political power. It’s a quixotic goal.
The US has public schools, the same as Europe.
Our costs are far higher and we get worst results.
This should inform you that mere copying of institutions doesn’t always have the same outcomes.
The ACA is a copy of the Swiss model. Why don’t we see Swiss pricing then?
@Harun: see Cooper’s post right above: salaries.
Obamacare lacks 90% of of the government regulations controlling prices that are present in the Swiss system, plus the canton governments are still running a large number of the hospitals.
‘One way out of this stalemate would be to effectively gut Obamacare in substance and change it to the consumer and market-based health insurance favored by Republican policy wonks’ –
Only problem, whenever someone proposes this they just end up proposing Obamacare.
UP NEXT: Bold Republican plan to replace Social Security with a system where gov’t collects payroll taxes from workers and employers and pays benefits to those over 67 based roughly on what they put in.
Isn’t the PPACA close to the German and French systems?
The Government policies that effect cost control must be done in the USA ate the state level.
It’s a bad copy of the Swiss system. If you took some serious quantities of hallucinogenic mushrooms, you could spot a few similarities to the German system. As others have pointed out, the greatest sin of the PPACA is that it’s based on the preexisting system in the U.S. That’s also the hardest part to fix.
“Saying that Obamacare’s supporters may be able to muster enough political maneuvers (Presidential veto, Senate filibuster, etc.) to prevent its repeal in spite of its failure as policy is hardly a ringing endoresement of it.”
Yet, pretending it is not the case is a lie. File it under “lies the base is told”.
A prediction or promise is not a lie. That was kind of my point. It may seem unlikely, but lots of inconceivable stuff ends up happening. Even wrong predictions or promises that people try and fail to fulfill are not lies.
“It may seem unlikely, but lots of inconceivable stuff ends up happening.”
Promissing to deliver goods you have every reason to believe you can’t deliver is the very definition of fraudulent misrepresentation. Evidently, ex post facto, you can say that if Santa Claus and Christ had paired up to help you, everything would have worked out just fine. Evidently, after the base’s rage served its purposes, the lies will be filed for future uses (see “You know, Paul, Reagan proved that deficits don’t matter”–Cheney and the crocodile tears shed over the deficit in the 90s and after ’08– but never from 1981 to 1992 or from 2001 to 2008).
You don’t have any evidence that the promise is being made in bad faith. Of course if they have no intention of following through, they are lying.
“You don’t have any evidence that the promise is being made in bad faith. Of course if they have no intention of following through, they are lying.”
No, I also have no evidence Reagan, Gingrich and Cheney was talking about the deficit in bad faith. Maybe they were merely delusional, if it makes you feel better. It just happens that there is method in their madness (the same thing happens with Democrat politicians, by the way).
Re: A prediction or promise is not a lie.
Um, it is a lie if you have good reason to believe that the prediction will not come true. If I said “It will be 90 degrees here tomorrow in Baltimore” wouldn’t you call that a lie?
Maybe the Democrats prevented it from being so.
If it were broken, it would be failing. It has gone better than or as expected in most cases. There are some flaws–inevitable with such a huge program to extend insurance to millions of people. Ideally, they would work to make it better, which has only happened in a couple isolated cases, sadly.
It won’t be repealed because Republicans have no feasible ideas to replace it. No real evidence of that changing anytime soon.
> It has gone better than or as expected in most cases
What predictions from its supporters are you referencing?
The number of people enrolled in Medicaid expansion states is even higher than predicted, the growth of overall health spending has slowed, it now expected to reduce the deficit by more than predicted, and the people who have acquired insurance under the ACA like it. One of the perceived failures–lower than expected numbers of exchange plan enrollees–can in no small part be attributed to the fact to positive developments, like fewer employers than expected dropping coverage for their employees.
We do this exercise for the predictions of the ACA opponents.
Should say “We *should* do this exercise”.
Only “Obamacare is broken” articles are offered or discussed here.
And it is absolutely prohibited to offer real functional replacements that are more comprehensive and less expensive because they can not be free market or profitable.
If is free lunch policy advocacy.
“Obamacare is broken!
Unfair, you can not demand I provide a better solution that is not more broken, whimper whine sob….”
Some of you call yourselves “economists.” If ACA was an economic benefit, why did the (authoritarian) state need to make it mandatory?
How many exchanges have gone bankrupt?
Why did my H/C insurance premiums rise 10% this year?
It’s higher taxes and an assault on health care.
There are large numbers of years with premium rises at that level, especially in the 1980s. Since the ACA has been implemented, has the aggregate h/c premium increase been larger than the average rise in h/c premiums before the ACA? It’s not proper to cherry pick data.
Car insurance is obviously desirable. Yet the state makes it mandatory. Strange…
Or, we could just ask whether PPACA has a bunch specific mandates that make premiums more expensive.
Oh look, it does. http://www.powerlineblog.com/archives/2013/10/why-does-obamacare-make-health-insurance-so-expensive.php
Also, “car insurance” is NOT mandatory. What you are paying for is “what if you hit something/someone with your car?” insurance, i.e. liability insurance. The states mandate it because at-fault drivers often have few assets with which to repay the damages they impose on other people.
“It has gone better than or as expected in most cases.”
Kind of like “my at least my garage didn’t burn down, I thought it was going to go with the house”
“It has gone better than or as expected in most cases. ”
LOL, I think that’s a very hard case to make. There are a few areas where it’s done marginally better than the original projection. Almost all of those involve giving something away at a steeply subsidized cost.
Other areas where it has failed to live up to expectations would include:
Promise: “If you like your health care plan, you’ll be able to keep your health care plan, period.”
Promise: “[T]hat means that no matter how we reform health care, we will keep this promise to the American people: If you like your doctor, you will be able to keep your doctor, period.”
Promise: “In an Obama administration, we’ll lower premiums by up to $2,500 for a typical family per year.”
Promise: “[F]or the 85 and 90 percent of Americans who already have health insurance, this thing’s already happened. And their only impact is that their insurance is stronger, better and more secure than it was before. Full stop. That’s it. They don’t have to worry about anything else.”
Promise: “Under my plan, no family making less than $250,000 a year will see any form of tax increase.”
Based on trends in insurance premiums, individual premiums would be 60-70% higher today than in 2008, which is probably 50% higher than your current premiums under Bushcare which double insurance premiums across the board during his presidency.
Except for the slow down in price increases that started in 2007, before Obama was even President.
TMC – that’s true, but it doesn’t seem like a counter argument. Growth rates went down, the guy in the Oval Office took credit for it. Rates have since gone higher, and opponents are certainly not shy about blaming O-care for it.
Government programs, especially ones that benefit millions of people, are rarely repealed.
Even in Kentucky the new governor is backing down from his pledge to eliminate the Medicaid expansion.
Obamacare has been substantially repealed by Congress dozens of times already, most recently just the other day.
The underlying realities haven’t changed — the US system, despite its flaws, was already the best in the world in 2009 at actually delivering the highest quality health care to the largest number of people possible, and the changes are both unpopular and in large part unworkable.
Even Vermont very quickly discovered it couldn’t afford single payer. As Megan has pointed out, there will be no big new cost reductions without big new rationing.
Politically, Obamacare has saved the GOP. It gave them the biggest majorities since the 1920s and they love running against it, but they can’t avoid a real attempt repeal if they take the WH in 2016.
At that point, it becomes interesting, because if the GOP holds the Senate but with less than 60 seats there will be pressure to repeal it via reconciliation (the same way it was passed). The GOP establishment would rather let the Dems filibuster, both to ameliorate the howling from the press and because Obamacare is such a politically useful debacle.
“…the US system, despite its flaws, was already the best in the world in 2009 at actually delivering the highest quality health care to the largest number of people possible”
I have only ever heard this as anecdote, but the opposite as research. Could you point me to research that balances these reports
Your statement is consisten wih these only if people not in the group you count as “the largest number of people possible” get the worst in the developed world.
International health system comparative research is very hard to do effectively and prone to bias. Therefore one should take all of this research with a grain of salt.
1) The Commonwealth Fund report (a group seeking nationalized US health care) ranks UK first in nearly everything, which is seriously out of step with other research in the field. The UK-based second report you link to paints a very different picture–the UK ranks last in mortality after heart attacks and among the worst in cancer survival, and does not lead anything other than vaccination rates.
2) A lot of things being measured here are not outcomes. Vaccination rates, hospital admissions, how a patient rated their doctor, and how many tests were unnecessarily repeated (to give a few examples) are not health outcomes and thus not good ultimate measures of how well a system performs. They are often related more to the mode of care delivery than health.
3) The measures are tend to be selected based on “what can we measure in each country?” rather than what measures really show the system performance. They are not necessarily representative of overall performance.
4) The high-level health outcome measures such as life expectancy and infant mortality are notoriously difficult to use for international comparisons. They face problems of confounding by lifestyle, as well as differences in measurement.
5) Assumptions about what kind of health system should be used are often built into the comparison. For example, the OECD has an indicator on who has “health coverage” that ranks every country with universal healthcare as 1. This only evaluates whether a country uses a preferred policy, not what kind of health care the population actually gets.
I’m NOT saying this proves the U.S. must be the best. The U.S. system has serious problems. However, I don’t think the evidence makes a compelling case that nationalizing the system is a no-brainer.
Simon Stephens, the head of the NHS (UK health service) is on the board of the Commonwealth Fund.
Interesting. I’m not sure if you are implying bias, but in general the NHS’s self-assessment of it performance is much more critical than this report.
Also, nitpick: he is head of NHS England only. Wales, Scotland, and NI have separate health services.
US healthcare costs much more than healthcare in the rest of the world.
There’s no good evidence that it produces better outcomes.
Many would prefer a more free market system. However, it’s usually impossible to shop on price, data on quality is rare and there are substantial barriers to entry (e.g., doctor licensing, drug patents). That’s not exactly the classical model.
Those things are only true because of government regulations. Drop the limits on medical schools, stop the anti-competitive insurance regulations and those things would go away.
It doesn’t produce better outcomes on average, because outcomes are only weakly a function of health care expenditures, confounding factors are much stronger, and palliative care generally isn’t measured in outcomes.
As with life vests, though, when you need that care, the averages be damned.
Mostly agree with the specific points, but saying that international comparisons are impossible or meaningless is I think incorrect. There are ways to organize health delivery and financing that have clear benefits over others.
2) Surrogate measures are appropriate when there is clear evidence linking them to a health outcome (e.g. vaccination rates), while other measures such as patient rating of their doctor are obviously not health outcomes, but most can agree they are meaningful. Who thinks that satisfaction with physician services is not a good thing?
3) Lack of ability to measure certain things, and lack of consensus on “what matters” are challenges that will never go away.
A key thing I have noticed is that wait times pretty much never factor into these measures, yet it is well known that other countries have much longer wait times.
I can’t imagine how wait times couldn’t be considered a quality issue, or how they aren’t impacting outcomes.
Not true, just like most of the other claims here.
If you have no one because of lots of reasons and no insurance, how long do you wait to see a doctor for non-critical problems that will become critical if not treated? Which doctor will see you if you have no money or insurance in the next 30 days after you call for an appointment?
Millions of people still have waiting times to see doctors that are in years – they get to see doctors when taken to the ER by EMTs.
steve — that’s waiting times to see a doctor when sick, not only are waiting times for things like orthopedic surgery often much longer, but the surgeries happen less often (the US does more surgeries per capita than any other country).
So, you would be happy to state without question that you are getting the best care in the world if you were denied health care for common chronic health problems because you were poor, until your life was threatened, say by gangrene from your untreated diabetes and you had to have it amputated with your ongoing costs much higher than providing you with free doctors, labs, testing kits, insulin, and related drugs to prevent the amputation? How about untreated chrones disease leading to your hospitalization and then death at a cost higher than treating it for free?
If you are single and poor, in two dozen States you can not see a doctor because you can’t pay so you are kept out of the doctor’s office. Maybe if you can get to an ER and wait for hours, losing your low wage job in the process, you can see a doctor who writes prescriptions you can’t fill because you have too little money.
These things don’t happen in dozens of countries spending far less per person.
Those things happen far more often in other countries. Greece at one point stopped treating diabetes with insulin.
Free health care under socialized medicine is like free food in North Korea — it’s only free when you actually get it, and they do far less health care than we do (see above).
BTW that’s another common misconception — treating a chronic condition is almost always more expensive than treating the acute symptoms later. And screening is usually even less cost-effective.
The real weakness of the US system is that everyone eventually dies no matter how much health care you give them. Keeping them alive only ensures they will incur more costs.
Some of the benefits are in things you wouldn’t think of, like far more private rooms (as Megan pointed out the other day) — and of course you can’t just roll costs like that back. Here’s a list from 2009:
U.S. does 2x as many transplants as OECD average
U.S. has best cancer survival rates in OECD
Death panels in Britain are putting people to death who could have recovered
Death panels: now in kids’ sizes too! Infants being left to die.
U.S. has more MRIS “it was found that Canada had 4.6 MRI scanners per million population while the U.S. had 19.5 per million”
U.S. has about twice as many MRIs as OECD average
The U.S. gets new drugs 1 year sooner “On average, the FDA approval came 1 year ahead of clearance by the European Medicines Agency (EMEA).”
“Prostate cancer mortality is 604 percent higher in the United Kingdom and 457 percent higher in Norway.”
“The top five U.S. hospitals conduct more clinical trials than all the hospitals in any other developed country”
U.S. performs more operations than any country in the world.
Lower U.S. life expectancy does not argue U.S. has worse health care due to lifestyle factors and differences in how infant mortality is reported.
Also, I don’t think you actually read your links.
One is from the Commonwealth, which rates systems based on how socialist they are.
One compares the UK to the OECD on certain measures.
The OECD report at least has some useful information, note that the US is ranked 1-3 in most measures of health care provision. Where we fall behind tends to be in things like admissions for diabetes, where our rates of disease are just higher.
“Obamacare has been substantially repealed by Congress dozens of times already, most recently just the other day.”
Problem solved, then, right?
“the US system, despite its flaws, was already the best in the world in 2009 at actually delivering the highest quality health care to the largest number of people possible.”
As sure as the world resting upon an elephant, who rests upon a turtle.
The point was that it is not even unusual for Obamacare to repealed, let alone impossible.
I understand statistics about health care provision seem esoteric, but things like “3x as many MRIs per capita” seem self-explanatory.
Only portions of the ACA can be repealed under reconciliation. And any attempt at repeal will necessarily involve some sort of replacement as well (to avoid creating chaos in the healthcare and insurance industries, and possibly crashing the economy as a whole a la 2008), which will be hugely controversial and probably bog down in committee, going no where.
Depends how bad the death spiral gets.
PPACA itself is creating chaos in the healthcare and insurance industries. The status quo ante is not going to “crash the economy” but it might help save it.
I don’t really get the position that Obamacare definitely needs major fixing, but it is also definitely not going to be repealed. If it is broken, then why is repealing out of the realm of possibility? Of course, a different reform could be passed after repealing it.
The claim it can’t be repealed seems mostly based on the adage “you can’t take away entitlements”. However, that seems like too much reasoning from a small sample size. There aren’t that many major entitlement programs in the U.S., so the fact that none of them have been repealed is hardly definitive. Also, entitlements are hard to repeal since the segment of the population benefitting from them cares a lot more than the population at large, making it politically toxic to do anything. But Obamacare is different: a lot of the people who are directly affected by it believe they are being harmed by it, so this changes the political calculus.
Laszewski identifies problems with Obamacare but offers no solution; he offers no solution because he isn’t that interested in a solution. The two major problems are risk pools and healthy penetration (especially among those who don’t qualify for subsidies). Put Obamacare insureds in the same risk pools as everyone else, first problem solved. End discrimination on account of age, second problem solved. As to the second problem, although he isn’t quite there yet (in age), if Mr. Cowen’s plan could charge him triple the premium his plan charges a young faculty member, he might be more interested in a solution. As it is, the absence of transparency with respect to group plans hides from plain sight what would be considered problems to solve; ignorance is bliss.
Are you serious?? Ending “age discrimination” (i.e. underwriting) would make the problem skyrocket to the moon. The problem is that healthy people don’t sign up because the rates are way too high and it’s too easy to get back on a plan. Ending “age discrimination” would make rates skyrocket even more for those people.
The poster’s first suggestion takes care of your objection. And for crying out loud, group plans at work all charge the same premiums for members regardless of age– the premiums are not cheap, but they are not at lunar heights either.
The uniform premium is a Federal mandate if the health benefits are to be both tax deductible expenses and tax exempt compensation.
I wonder why no conservatives have attacked the lack of ratings for employer health benefits and demanded that be repealed so 50 million older employees would see their employer benefit costs double or triple so younger workers would see their health benefits fall, unless they have a pre-existing condition….
Meanwhile, people are continuing to see their lives ruined- through no fault of their own- after getting sick and not being able to pay the insanely high health care costs in this country.
Note that these are people with insurance who apparently don’t qualify for medicaid but can’t afford to pay their deductible.
Note that healthcare is expensive.
Note that the story you linked to contains data where insured and uninsured are mixed together.
Note that the insured in the story you linked used to have a deductible of infinity.
Obamacare is broken only in the sense that the entire US healthcare system is broken.
A major goal was to increase the number of people with insurance. It did that.
Opponents predicted all sorts of disasters – massive harm to the economy, massive harm to people’s ability to get jobs or work their desired number of hours, massive increases in individual healthcare costs (as opposed to aggregate costs). None of that happened.
Even the NY Times has run many stories recently about how Obamacare is failing to deliver. It truly is not delivering what its proponents claimed it would do, and what it is doing now is not sustainable. Many of these problems were predicted by critics. Of course some of the warnings were over the top and did not come true, but that is politics for you.
Well the CBO predicted some things when the law was passed, and actual results were a bit lower:
Nothing Avik Roy says about healthcare should ever be read.
He has never been right about anything.
Avik Roy has about the same track record on healthcare as John Bolton does on foreign policy.
Actually, Bolton might be better.
Meanwhile, today’s Post has an article outlining how the biggest, and at one time legitimate-seeming, conservative talking point against Obamacare just…never happened.
Critics had predicted that employers would shift workers to part-time schedules to avoid a requirement that they provide insurance to full-time employees. There was also a prediction that people might opt to work less because they could now obtain insurance through the marketplaces or expanded Medicaid coverage — neither of which was borne out by the data.
The article as a whole is a lot more qualified than that (emphasis added).
“The new analyses are still early, since a key requirement of the law began to be phased in just last year, but they add to a growing body of evidence that, if the law has had any effect on the labor market, it’s been a small one.”
“Last month, the Congressional Budget Office warned once again that Obamacare would discourage the equivalent of 2 million Americans from working by 2025, since they can get health insurance without relying on an employer…While the new studies don’t rule out the dim long-term forecast, they do offer some reason for optimism”
There are “concerns” but without much support of the data. The seismic shift many warned about has been absolutely wrong. However, in some respect, a little dip in the number of people working, who are in poor health and only doing it for the insurance, would be a good thing.
If one were to go back and evaluate all of the “Obamacare will cause this terrible thing” arguments against it, it would be interesting to see how many came to fruition, how many happened on a much smaller scale than predicted, and how turned out to be simple scaremongering.
A great tactic in criticizing public policy is the “just you wait”. It is very hard to rebut, for obvious reasons, but it fails as an argument against a policy that has already been implemented, because it is not supported by empirical evidence.
Well, let’s see, Obama promised no one would lose their doctors or plans, and that premiums would fall by $2500.
Next we can get into all the co-ops that are going bankrupt, and if there’s time maybe the disastrous, expensive website failures and all the stuff that hasn’t been implemented yet.
“Last month, the Congressional Budget Office warned once again that Obamacare would discourage the equivalent of 2 million Americans from working by 2025, since they can get health insurance without relying on an employer”
Why is that a bad thing?
Is becoming wealthy a bad thing, as that can reduce the incentive to work? I’d imagine most people would be willing to take the risk.
People worry that they won’t be able to get work, not that they don’t have to work.
It would be a fine thing if people had earned and saved enough to quite working on their own dime, but it’s not a good thing if they’re able to quit only because their health insurance will be heavily subsidized. One place this comes up is with early retirees below the age of Medicare eligibility. Because health insurance is so expensive in this age bracket (and for good reason), many of these folks would ordinarily keep working until 65. But with Obamacare, they’re protected by the 3:1 age band ratios and, with investment income, properly tuned 401K withdrawals (possibly combined with a bit of part-time work), they can adjust their incomes to qualify for maximum subsidies on the exchanges. And this is true regardless of high their net worth may be — since Obamacare subsidies depend only on income, not wealth:
Perhaps this hasn’t happened to any great degree, but it seems inevitable — whenever government offers free money, it inevitably gets lots of takers. And in this case, the takers are likely to skew towards high-net-worth folks who have plenty of both pre and post-tax retirement savings and who are, therefore, in the best position to take full advantage.
First, if this analysis is correct, it’s an easy fix. As precedent, the Earned Income Tax Credit has a rule that people above a certain threshold level of investment income are ineligible. Second, the notion that PPACA will disproportionately benefit high net-worth people doesn’t pass the laugh test. Surprisingly enough, people with lower modified AGI tend to be poorer on average than people with higher modified AGI. Yes, a handful of people will always be able to game the system. If there are a lot of people gaming the system, then we should start talking about a fix such as the one I cited above. But if there aren’t a lot of these people, then it might not be worth fixing. There is no such thing as perfect targeting.
I’m one of these people, and early retired last year. I’ll have no problem keeping our joint AGI below $36,000 by living off after-tax savings until we’re 65 while deferring pension, Social Security and 401(k) withdrawals.
But I suspect we’re a pretty small group. Wealthy enough to have 5 years or so of after-tax living money stashed away, plenty of tax-deferred savings to live on later, but not so much money so that it’s still possible to keep AGI under the threshold for ACA subsidies.
Gaming the system? Well, I did pay a few million in income taxes over my working career.
Another possible fix: say that people above a certain age with no wage income need to show proof of a disability or unemployment insurance claim to qualify for full subsidies. Otherwise, the subsidy gets docked and, again, investment income or withdrawals from retirement accounts could easily be factored into the subsidy formula.
It may well be cheaper to lower the Medicare age and raise payroll taxes instead of giving subsidies to people to purchase private health insurance. But that’s socialist and we can’t have that.
Another possible fix: say that people above a certain age with no wage income need to show proof of a disability or unemployment insurance claim to qualify for full subsidies. Otherwise, the subsidy gets docked…
So the unemployed poor get no subsidy?
and, again, investment income or withdrawals from retirement accounts could easily be factored into the subsidy formula. – See more at: http://marginalrevolution.com/marginalrevolution/2016/01/obamacare-in-2016.html#comment-158895519
Investment income is factored into the subsidy formula, if it’s taxable. Tax-free investment income isn’t currently reported to the IRS, but I suppose it could be. It’s often negative from year-to-year, though, depending on equity returns.
withdrawals from retirement accounts could easily be factored into the subsidy formula.
They already are. You’re shooting from the lip, instead of thinking.
Sorry, meant to say permanently unemployed poor get no subsidy. The point being that unemployment claims are of limited duration.
First, if this analysis is correct, it’s an easy fix. As precedent, the Earned Income Tax Credit has a rule that people above a certain threshold level of investment income are ineligible.
There are lots of possible fixes. Use wealth as well as income to determine subsidy eligibility. But NO fixes are easy fixes politically. Republicans simply aren’t interested in making Obamacare work.
Second, the notion that PPACA will disproportionately benefit high net-worth people doesn’t pass the laugh test
Of course Obamacare as a whole won’t disproportionately help wealthy people. But in the particular case of getting subsidized health insurance during early retirement, wealthy people are much better positioned to take advantage. And anything that eases early retirement not only hurts the risk pool for the ACA, it also exacerbates the shortfalls in Medicare and Social Security.
They did save enough to retire early– after all, healthcare is far from the only thing you have ti spend money on. They obviously have enough $$ to pay their other bills.
Ricardo: “It may well be cheaper to lower the Medicare age and raise payroll taxes instead of giving subsidies to people to purchase private health insurance. But that’s socialist and we can’t have that.”
Your solution of expanding Medicare to bring in more suckers would do Bernie Madoff proud.
Comments like this are why it is really difficult to believe some people are really serious about health care reform. For the longest time, the mainstream line coming from conservative Republicans is that we need to sever the link between employment and health insurance to encourage more small business development and entrepreneurship and create a more dynamic labor market. PPACA does that in part and now we are starting to see complaints that PPACA will discourage people from “working.”
Note that any plan that eliminates tax breaks for employer-sponsored coverage — which many Republicans have advocated doing away with for years — and makes it easier to buy individual coverage or contribute to HSAs will have the effect of pulling some people out of full-time employment. If that is what you want, you should own it instead of criticizing PPACA for having the same effect. If it isn’t what you want, then be clear that you disagree with most of what conservatives have been saying about health policy since the time of Milton Friedman.
So, you see it as great that sick people with good friends in corporations with great benefits can pad the payroll in order to provide free health care for a friend in need, all in the expectation that at some point he will need similar favors and will get the same help from his friend’s kid or spouse?
I knew an engineer that worked for the TSA part-time just to get the Federal health benefits for a price way below the “free market” individual rate or even the COBRA rate of his last job. He said about a third of the TSA agents took the job only to get health benefits for themselves and family. This was during Bush’s first term into second. They saw the job as totally stupid, but you do what you must to get affordable high quality health benefits.
Republicans accomplish nothing because they are led by men like A.M. McConnell, who is addicted to Capitol Hill gamesmanship. Replace McConnell, get rid of stupid parliamentary rules, and elect a new President, and maybe they will get something done other than noodling with marginal tax rates and tossing candy at the Chamber of Commerce. If you’re holding your breath, you’ve not been paying attention.
“The big question that will remain is: Who will fix Obamacare?”
The big answer is: the same people who fixed Social Security and brought peace and stability to the Middle East.
I am not sure why Tyler likes Bob L. so much. He is big on sweeping statements and selected usage of statiatics. He has never states how he would fix Obamacare and you would not learn from is article that total private insurance is up after 2013 and unisurance rates are down.
There are certainly problems with Obamacare–mostly centered around the fact that many don’t understand the value of health care until they are sick and we still don’t have any pricing transparency.
Because Tyler is only interested in evidence that fits his preconceived notions of how things are.
>Republicans can’t admit it won’t be repealed.
Well, that’s dumb.
Obamacare hasn’t even been fully implemented yet, as Obama himself keeps kicking the most disastrous aspects of it further and further down the road.
Obviously these horrific parts of the law can be repealed, as well as some others that have already been inflicted on the country. Dems will of course shout “Haha, you didn’t repeal the whole thing!!” but that is no matter.
I take it you support free health care by printing money?
The biggest objections are all related to paying for health care.
Nothing quite as worthless as an article attacking the ACA for making healthcare in the US extremely expensive. Unless of course it is an article that ignores the fact that the healthcare system in the US has been very expensive for a long time while failing to mention that employer provided insurance is far more expensive than insurance on the exchanges.
And Republicans can’t offer any fixes as they don’t know any and don’t want any.
Republicans have offered lots of alternative plans. This page mentions some: http://healthaffairs.org/blog/2015/09/18/what-would-republicans-do-instead-of-the-affordable-care-act/
” Public discussion concerning ACA repeal proceeds without consideration of the real and significant policy impacts and consequences. Public conversation needs to better educate Americans about the many significant policy impacts that would be wrought by repeal of the ACA.”
And those plans amount to “repeal and don’t replace.” There is no “plan” in that document you linked to. Simply announcing the desire of various Republicans to repeal all or part of the ACA. The only policy beyond “repeal it” that is discussed is basically keeping provider cuts and other savings in Medicare that the Republicans ran AGAINST for the 2010 midterms.
I linked to that blog simply because it lists some proposed alternative plans. If you google the plans themselves you can get more information.
When one of them is written into a bill presented to a house or senate committee, please let us know.
Then point out all the Republican support for the bill, plus all the health care industry lobbyists showering money on the supporters of this bill.
Then I’ll point to the conservatives ripping it to shreds and calling for those Republicans to be primaried.
@mulp, multiple of them already have been
Those aren’t alternative plans, they are sound bites for the media.
From that very link:
“Unfortunately, the proposals now being advanced by the Presidential candidates are far less than comprehensive, and leave many more issues unanswered than answered.”
“Those aren’t alternative plans, they are sound bites for the media.”
This is untrue. They really are detailed alternative plans. Here is a summary of one on Wikipedia: https://en.wikipedia.org/wiki/Empowering_Patients_First_Act
As for the quote, maybe the plans leave questions unanswered, maybe they don’t. Maybe they are great, maybe they are terrible. But to determine that would require actual discussion of the proposed policies, rather than hand-waving that “Republicans don’t have any ideas”.
“Though narrative versions of Burr-Hatch-Upton were released in 2014 and 2015, the authors have not translated their proposal into legislative language that can be evaluated by the Congressional Budget Office (CBO).”
Narrative versions are not plans. They are nothing more than sound bytes using a couple of bullet points.
Perhaps as with ACA you’d have to pass the plan to know what’s in it.
“Narrative versions are not plans.”
This strikes me as goalpost-shifting, but no matter. Do plans that were actually introduced as bills in Congress count as plans? Because several of these were.
The claim that Republicans have no plans for replacing Obamacare is obviously false. I am surprised at the amount of defense people are mounting of this claim in spite of the evidence.
The claims are less interesting as claims than as evidence of the unexamined echo chamber on the left.
It’s really easy to believe ridiculous things when you never see a contrary opinion.
I don’t think the right is more introspective by nature, but rather by necessity, because it’s much harder for them to avoid the enormous bias against them in media and academia, while lefties just have to avoid right-leaning media.
There are certainly Republican priposals, and some of them have some good ideas. If the Obamacare debate teaches us anything, though, it’s that the devil is in the details. Creating a solid enough plan that it could be scored by the CBO and allow pundits could compare coverage to the ACA seems like a good threshold to target.
“it won’t be repealed”
Does not that depend on the results of the next election?
A GOP president and senate [along with the certain GOP house] will repeal it. Parts may survive but not the whole and the repeal of the act itself would happen so that it can never be referred to as “Obamacare” again.
Odds are the GOP will not be so successful but it is not impossible.
Technically, yes. But have you looked at the Senate seats that are up in the next election? Also, the current GOP presidential field seems to be in a race to see who can make themselves most unelectable against Clinton. Republicans may also get a little shy about repealing if they know they don’t actually have any agreement on what to replace the ACA with. I don’t know that voters or even GOP members of Congress would find a straight repeal with no replacement acceptable.
I think it likely that if Republicans win the presidency they will also hold the Senate. When you look only at competitive seats, the situation doesn’t look so bad for them. They only have to win a couple of competitive races. Of course, winning the presidency is no sure thing.
I agree about the repeal without replacement, but I think that if there is a Republican-controlled government in 2016, they will get an alternative plan done. Too much has been invested in the call to repeal the ACA to not do this. While there is diversity in the Republican proposed replacements, I don’t think this would be hard to overcome. Overcoming a filibuster in the Senate would probably be more difficult, but also achievable in this scenario.
“Overcoming a filibuster in the Senate would probably be more difficult”
Under the current rules as I understand them, since Obamacare was passed under “reconciliation”, a repeal bill also brought under “reconciliation” is not subject to the filibuster.
The filibuster has already been partly eliminated, if it does stand in the way of an Obamacare repeal, would it survive?
The filibuster was only eliminated with respect to judicial nominations. However, it’s entirely predictable that since the Democrats restricted the filibuster for political reasons that a Republican controlled Senate would further restrict a filibuster.
Harry Reid made a foolish decision when he went down that road. I think he must have bought into the 2008/9 rhetoric that demographics had permanently crippled the Republican party and that the Democrats would be in ascendancy for decades.
You are not correct in any part of that thought process. You need to look into what part of the ACA was done in reconciliation.
Republicans could eliminate the filibuster to repeal the ACA, but I doubt they would want or need to do that. In the scenario where Republicans have full control of government, the Democrats are unlikely to be able to mount monolithic opposition. In the 2018 Senate election there are only 8 Republican incumbents and 23 Democrats (including a number in conservative-leaning states). They would probably be able to find some Democratic votes for repeal with a modest amount of compromise.
Or they just get rid of the some of the less popular parts of the law (individual mandates) and then claim they did what they promised: Obamacare has been replaced by GOPcare!
“But have you looked at the Senate seats that are up in the next election?”
Yes, that is why I said odds are against it.
“Also, the current GOP presidential field seems to be in a race to see who can make themselves most unelectable against Clinton. ”
Maybe. Fortunately, she is a terrible campaigner with over 50% of the people having an unfavorable opinion of her.
I read these threads and wonder where all these Obamacare haters got healthcare ca. 2005? Was there some golden ticket I missed. As a self employed lawyer I’ve been buying insurance and negotiating with companies for 20 years and it was always hell. It’s still a racket, of course, but Obamacare has improved things in every aspect.
If you’re talking about buying a plan just for yourself, that was never hard. Now it’s also not hard but costs are way higher at least for the young and/or healthy.
We don’t live in the same country apparently, or else, where were you when I needed you. I was basically buying catastrophic in 2005 as the deductible was so high and it wasn’t cheap at all. I switched almost every year trying to eke out a better deal.
I had a $60/month plan with a $10K deductible, which worked just fine for me when I had an emergency appendectomy. I didn’t evne hit the deductible because the plan discounts along brought the cost down to $6000.
Now if I was spending $300/month on insurance, I would burn through that amount in 2 years. So unless I had the equivalent of an emergency appendectomy every two years things would have gotten worse for me. Even with subsidies spending $100/month on insurance, one would have to have a very high chance of getting into a motorcycle accident or similarly having catestrophic health events to make the ACA worthwhile. The Bronze plans aren’t even that much better than my $10K deductible plan.
I am willing to bet your plan had a very low cap too. The only reason there were cheap plans out there is because they capped pay-outs at c. 25K– for life. A true catastrophic plan with no cap is going to be pricey since it leaves the insurer liable for payments that may exceed a million dollars. The fact that caps are now illegal explains much of the high cost of ACA plans.
It was easy to buy a plan. It was very hard, and expensive, to buy a plan that covered anything and/or was not cancelled when you got sick, in addition to being subjected to incredible scrutiny if the medical condition was expensive to treat.
How soon we forget the problems of health insurance rescissions and the common practices of insurance companies before the ACA:
Recissions were rare, and almost always only happened when the person in question actually had a pre-existing condition.
The contoversial cases are cases where it’s not entirely clear if the condition was really-pre-existing.
Did a recission happen to YOU? What was YOUR personal experience, not what you read about anecdotally.
I call bs that you had an individualized $60/month plan in 2005 or thereabouts. And do you even know what a deductible is? If the emergency appendectomy costs $6000 (right) and you had a $10,000 deductible – you should have paid the $6,000.
P.S. Recission cases were far from rare. I don’t research for free, but if you want me to pay me for an hour I’ll produce citations out the wazoo.
I think Hazel is saying that she did pay the $6,000, and that would still be cheaper over time then paying more premium for a lower deductible plan. But I agree that the $60 monthly premium isn’t credible unless it was employer-subsidized insurance.
I analyzed all of the 2016 ACA plans available to my wife and I (Bronze, Silver and Gold) against our full actual claims experience for 2014, and again for 2015. Before ACA subsidies, they all had an expected cost to me in the $18,000 – $20,000 range. I was surprised how tight this range was. We’re both in our late 50’s. The differences were due to interaction of premium level, co-pay, deductible and out-of-pocket limits. I had a 3 night hospitalization in 2014.
As I see it, the advantages of insurance are negotiated pricing and out-of-pocket limits. Everything else is window dressing.
Do you want me to photocopy my monthly premium bills and post them? I might still have them in a filing cabinet somewhere.
I assure you that I definitely did have a $60/month premium. It was called Golden Rule and I was living in Tucson Arizona at the time.
It was NOT employer subsidized insurance. It was insurance I purchased myself on the individual market.
Maybe it was cheaper than what you could get in California because the cost of living in Arizona is lower, but it certainly existed.
Hazel, Golden Rule plans were like Cancer Insurance.
Please specify what the coverage was and what the deductible and exclusions were before you call the former Golden Rule products “insurance”.
What you got for $60 was probably a $20k coverage for hospital stays.
It was a $10K deductible, and it was NOT hospital-only insurance. I don’t recall the other features, exclusions and such. I wouldn’t be surprised if it didn’t cover maternity. In later years they actually reduced the deductible to $8K for the same price, presumably since I was not hitting it.
I do know I did get plan discounts on doctors visits and non-hospital services like labs and such.
Here is an article about Golden Rule plans from 2005:
“As an average across all markets, a single male in his mid-20’s can buy health insurance at an affordable monthly base premium of $40 with a Golden Rule Saver 80 Preferred Network plan”
“”Saver” options within each of the three types of plans offer Golden Rule’s lowest monthly premiums and are designed to appeal to millions of Americans who thought they could not afford health insurance until now.
The “Savers” provide customers with protection from the more costly medical expenses that can break a family’s budget, like hospital confinements, outpatient surgeries or CAT scans. Premium costs are lowered by limiting the amount of coverage for the more routine expenses, like doctor visits. ”
“All Golden Rule customers have access to Savings-Based networks of physicians and facilities with Preferred Networks available in many areas that can further reduce health care expenses. In addition to the discounted medical care, the Saver series also provides a supplemental prescription drug discount program at no additional cost. ”
So it doesn’t cover office visits, but you still get the network discount. Which sounds like what I had. I do recall also getting the prescription drug discount.
Here’s a more detailed description of the “Saver 80” plan which sounds pretty close to what I had. Note that it was being offered for $40/month in 2005, and the maximum deductible is $10K which was what I had. I was a mid-30s female at the time so I assume that’s why it was a bit more expensive for me.
Hazel was covered by Golden Rule– one of the biggest scams in the insurance industry,. Had she actually needed to depend on her plan she would have been screwed.
Really, do you have any proof that Golden Rule was a “scam”? Cite please.
And do note that I did actually use the insurance. I had an emergency appendectomy and received about $24,000 in plan discounts.
This is an interesting idea…relatively cheap insurance that isn’t intended to actually cover much health care, but passes through negotiated discounts so that if you do need care you’re not gouged by the grossly inflated “rack” rates that US medicine otherwise charges.
I, too, had a Golden Rule plan (though not as high deductible as Hazel’s). It was a good deal, definitely not a rip-off or scam.
Ya’ gotta love people who reply to a comment without even thinking of reading the link in that comment.
No. As is shown in the link that was provided.
The link has a single anecdotal example and says that nobody knows how common they are.
It merely asserts they must be common because they have sparked outrage and lawsuits.
It actually covered plenty, it just happens to have a high deductible. It’s designed for the purpose insurance ought to be for – to protect yourself from expenses you can’t afford. Not an all-inclusive pre-paid body-maintainance plan.
An insurance plan that actually insures against large medical expenses.
Health care is SUPPOSED to be expensive. That’s why people go to medical school to become oncologists and neurosurgeons and radiologists and anesthetists. That’s why big companies own hospitals and ambulance services. Oddly, however, like in other fields, workers in the medical profession are no longer what might be called “craftsmen”. They don’t operate on the basis of experience and intuition. They’re now “technicians”, a very different thing. There are sophisticated mechanical and electronic interfaces between medical personnel and patients that provide diagnoses and treatment options that no longer require gifted insight. People at all levels in the medical profession are cashing checks that should be written to machinery.
Or better yet, SAVED BY THE PUBLIC
“I think their dramatic announcement surrounding their very real and huge losses late last year was more about negotiating favorable terms in the future than getting out of what is now the entire individual health insurance market”
Who else said that? This simply is the way we do health care policy in this country. President Obama wanted a form of universal coverage. He got it. Now we’re going to slog through years of tuning ( not fine ) it. That was the point of the very good post. It’s not my plan, but I appreciate the views of people trying to tune it, because my plan, a version of Milton Friedman’s plan, just isn’t going to make it. Too many special interests at the table.
When people make predictions, I always want to find out about them.
Here is what Bob Laszewski says about himself in Forbes:
I am one of a kind having spent 20 years in the health insurance marketplace and 20 years inside the Beltway. I ran two health insurance businesses before coming to Washington, DC to start my own health care policy and market consulting business. Over the last 20 years my clients have been the people who run insurance companies, hospitals, and physician practices. “
He sounds like someone who would be pretty knowledgeable about the American health care insurance market.
He sounds like someone who profits from protecting the ones who profit from America’s lack of a decent healthcare system.
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