The incidence of the ACA mandates

Here is Mark Pauly, with Adam Leive and Scott Harrington (NBER), this is part of the abstract:

We find that the average financial burden will increase for all income levels once insured. Subsidy-eligible persons with incomes below 250 percent of the poverty threshold likely experience welfare improvements that offset the higher financial burden, depending on assumptions about risk aversion and the value of additional consumption of medical care. However, even under the most optimistic assumptions, close to half of the formerly uninsured (especially those with higher incomes) experience both higher financial burden and lower estimated welfare; indicating a positive “price of responsibility” for complying with the individual mandate. The percentage of the sample with estimated welfare increases is close to matching observed take-up rates by the previously uninsured in the exchanges.

I’ve read so many blog posts taking victory laps on Obamacare, but surely something is wrong when our most scientific study of the question rather effortlessly coughs up phrases such as “but most uninsured will lose” and also “Average welfare for the uninsured population would be estimated to decline after the ACA if all members of that population obtained coverage.”  The simple point is that people still have to pay some part of the cost for this health insurance and a) they were getting some health care to begin with, and b) the value of the policy to them is often worth less than its subsidized price.

You will note that unlike say the calculation of the multiplier in macroeconomics, the exercises in this paper are relatively straightforward.  They also show that people exhibit a fairly high degree of economic rationality when it comes to who signs up and who does not.

It has become clearer what has happened: members of various upper classes have achieved some notion of “universal [near universal] coverage,” while insulating their own medical care from most of the costs of this advance.  Those costs largely have been placed on the welfare of…the other members of the previously uninsured.  So we’ve moved from being a country which doesn’t care so much about its uninsured to being…a country which doesn’t care so much about its (previously) uninsured.  I guess countries just don’t change that rapidly, do they?

I fully understand that Obamacare has survived the ravages of the Republican Party, and it was barely attacked in the recent series of debates, and thus it is permanently ensconced, and that no better politically feasible alternative has been proposed.  At this point, the best thing to do is to improve it from within.  Still, there are good reasons why it will never be so incredibly popular.

Comments

'I guess countries just don’t change that rapidly, do they?'

Sure they do - the U.S. went from being a proud beacon of a nation opposed to torture, both in its Constitution and more importantly in centuries of proud tradtion, to one that used torture against the innocent, with officials betraying their oaths to the Constitution to broad American public approval, in less than a decade.

Nonsense. The US and almost all other western nations didn't hesitate to torture or do anything necessary to win when faced with a dangerous enemy in the past.

I wonder if Canada, Iceland and Norway torture.

For the most recent Supreme Court appointment (Canada), the prime minister tried to appoint the ONLY judge in the ENTIRE country who thought it was OK to detain for years without a real trial (Guantanamo) and torture a child soldier.

Fortunately, the judge didn't meet some vague criteria, and the courts barred the prime minister's choice.

That having been said, I'm pretty sure that, outside of the current governing party, there is a sufficiently strong institutional imperative and public support against torture that it will not become a part of Canadian practice any time soon.

They don't need to - they outsource their torturing to other countries, such as the United States.

OK, but what explains the reaction to 2011?

That wasn't a change in stated preferences, not in actual preferences. It's the kind of thing people have strong feelings about until it actually happens, and realize they are wrong.

Other similar situations involve hating gays while never meeting one, having a firm view of monogamy while in a happy marriage, and talking about abortion when nobody around you has had an unintended pregnancy. Only when our opinions actually affect us, we really understand if our original POV was really a strongly held belief.

The US had many wars before 9/11. So whatever our preference was, it was not just stated.

I think its useful to distinguish the institutions engaging in torture. Torture has long been seen as necessary and/or effective by substantial numbers of Americans. There is a strong tradition of local police torture and state prison torture in the US, especially against minorities. The CIA has worked hand-in-glove with foreign regimes that engaged in torture for decades during Republican and Democratic administrations (Pinochet, Mubarek, Suharto, the Shah, etc.). And there is the vast history of vigilante torture (from riding undesirables out of town on rails to lynching). The US military, however, has a tradition going back to George Washington of treating captives humanely. The military's record is far from perfect (Indian Wars, Mylai, etc.) but the military's stated and revealed preference is strongly anti-torture.

I remember a time, not so long ago, when accusations that foreign countries tortured people were equivalent to calling them evil, and that when evidence started to mount of torture within the American system, that quite a lot of people were fairly adamant that this implied prison sentences for the offending "interrogators"/torturers. Instead, "advanced interrogation techniques" have been legalized.

The USA lost a lot of reputation on this one.

Has torture ever produced credible evidence of anything?

I dont agree. If US/EU had any positive reputation can only be due to some propaganda, nothing more. It's not good vs bad but bad vs worse...

agree

Nathan is right, although the approval of "advanced interrogation" was revoked by Obama. Sadly, the US did not live up to its obligations under the conventions against torture to prosecute the torturers, since the approval went all the way up to the top, choosing instead to sweep it under the rug. Although that too is the American way; Nixon was pardoned, after all.
And no, torture has never produced credible evidence. Because when you torture someone until they 'talk', once you break them they tell you whatever you want to hear. It is well known by actual interrogators before 9-11, but that was all tossed out as part of the 'reality based community' back in 2001.

Except the whole capturing of bin Laden thing.

First of all, most of the military does not consider waterboarding to be torture, nor do they consider bright lights or making someone stand for a few hours. Considering that the US military waterboards their own soldiers as part of their training, that tells you the military doesn't consider it torture at all.

Secondly, your question about whether it produced any evidence, the answer is yes. We got bin Laden. Without waterboarding we wouldn't have found him. Khalid Sheik Mohammed was waterboarded four times. He coughed up the name of bin Laden's courier, a person who had been on various terror lists but was not considered a major player. When Mohammed gave up the courier, the CIA followed him right to bin Laden. Without waterboarding, bin Laden would still be alive.

Mssr. RL, you have been misinformed. According to this article from Vox.com back from December of 2014, the Senate Intelligence Committee report on the CIA's torture activities concluded that the CIA did not find Osama Bin Laden using torture:
http://www.vox.com/2014/12/9/7361091/cia-torture-bin-laden

The US military does consider waterboarding torture. The tactics you speak of that soldiers are subjected to are part of SERE school. SERE is an acronym for Survival, Evasion, Resistance, and Escape. The US military trains its soldiers to withstand certain amounts of torture since they anticipate that many nations will torture our troops during wartime if captured, or when our soldiers are conducting clandestine operations in countries angry that the US sent soldiers in to spy and gather intelligence without their knowledge.

Christopher Hitchens back in 2008 gave a report on what it was like to be waterboarded, and he concluded that it was most certainly torture:
http://www.vanityfair.com/news/2008/08/hitchens200808

We subject our troops to it, so they won't break immediately under torture, and so they know what to expect. But everyone will break when the bamboo shoots, cattle prods, electrodes to the gonads, physical beatings with truncheons and crowbars, etc. are brought out. But what you reveal when being physically tortured is utter garbage. The best interrogators will tell you that the only effective interrogation methods are building rapport, persuading your subject to talk, listening, and having fact checkers and informants who can independently corroborate what your subject is telling you.

What allowed the CIA to find Bin Laden was what a detainee volunteered before any torture was ever used. After he was tortured by the CIA, he gave no further, useful information. The CIA will always reserve the right to torture. It is an intelligence agency after all. But we don't live in a ticking time bomb world, and torture is needless brutality that turns our CIA and other associated agencies using such methods into torturers for torture's sake as we inflict needless physical pain and suffering on people out of revenge and blood thirst rather than being on a real quest to find the truth.

We learned more about organizations such as Al Qaeda, or their precursor organizations, by holding a public court trial when the World Trade Center was bombed back in the early '90s. To really bring terrorist organizations to heel, you have to cut off the financiers (often times deep-pocketed malcontents who are part of the extended Saudi Arabian royal family, which is massive), or a government funneling money to a group such as Hamas or Hezbollah such as Syria and Iran. But terrorists don't exist in a vacuum, and they are most frequently people being paid by some government somewhere who is just going to great lengths to hide where the money is coming from.

Soldiers don't fight on empty stomachs for long, and terrorists don't hang around to stage terrorist actions unless someone keeps the paychecks and training funding coming.

Thank you for your clarifications in this regard.

Sure it did. Uh-huh. Because the White House would never lie about something like that. Nope.

http://www.lrb.co.uk/v37/n10/seymour-m-hersh/the-killing-of-osama-bin-laden

Hey prior_approval, you've made innumberable previous mentions of Walmart losing a billion dollars in the German market. Care to comment on VW's cheating and potentially epic EPA fine?

"Volkswagen could face $18 billion penalties from EPA" To put that figure in perspective, VW's entire market cap is only $56 billion. So, potentially 1/4th of the companies net worth could be fined away, because it was caught defrauding the EPA on emission test results.

I see your point. But the reality is different. Prior to 1963 it was legal in the US to torture your slaves. Since then there were numerous interventions, dirty wars, secret wars, carpet bombing campaigns, support for appalling dictators such as Trujillo and Pinochet, and on and on. Torturing a few guys in Iraq and Guantanamo, wasn't all that bad if you look at the not so distant past.

You have a rather twisted view of the past of the US. Light reading: https://en.wikipedia.org/wiki/Phoenix_Program.

America has used large-scale torture as a weapon in nearly every conflict it's participated since independence.

[post unrelated]

So enough to preen morally but at someone else's expense.

The effective marginal costs that imprison people in poverty and the unbelievably smarmy defenses reminded me of the political Catholicism in Quebec of years past. Self righteous elitism and pursuit of policies to keep people stupid and poor. Ugly and disgusting.

This is political Catholicism everywhere. Chain people to poverty and hope poverty will chain them to Rome. If there is money to be made in the process of doing so, all the better.

That's reminiscent of a large chunk of the traditional policies of the (British) Labour Party.

Indeed. There is a left ring variety (recall Orwell's Oceania) as well as a right wing one. Indeed, the first time I saw the formulation "chaining people to poverty to chain them to ..." was as a description of Stalin's policies in a book discussing the changes in the Soviet Union in the 60's.
Left, right. Just look both ways before crossing the street, will you?

Nothing like a large pool of reserve labour to make sure that big business can upscale production without having to sacrifice to much in the way of wages/profits (an existing argument)

First conservatives whine that liberals in America aren't willing to fund their welfare programs with broad based taxes that affect the middle class a la Europe, but rather focus on the rich. Then liberals pass Obamacare, which apparently is analogous to a broad based tax-and-spend where the net benefit phases out somewhere in the middle class, at which point point there's a net burden: "even under the most optimistic assumptions, close to half of the formerly uninsured (**especially those with higher incomes**) experience both higher financial burden and lower estimated welfare." (Emphasis added.). And then conservatives whine about that too, all the while making approximately zero constructive suggestions for how to improve the law

So "most uninsured will lose" is not a problem in your book?

I'm confused by how "close to half" referred to in the abstract becomes "most" in your comment. But yeah, I don't have a ton of synpathy for middle class folks who refuse to buy health insurance even though they can afford to do so. I mean, there was a period of my life where I didn't have health insurance and I could have afforded to get it -- and you know what? In hindsight, that was really irresponsible! If I go really sick, my parents/siblings would have had to pay for whatever medical care I needed once my own savings were depleted, or else I would eventually have to go onto Medicaid, etc.

Dan, your comment is a good example of how Obamacare was structured to *punish* the uninsured (the freeloaders), not to help them. If you dispute that, reread your comment.

It strikes me as pretty silly to frame this as punishing "the uninsured" as a whole (as both you and Tyler do), when what it really seems to be doing is operating as a transfer from the richer uninsured to the poorer uninsured.

I knew plenty of young males who practiced extreme sports without insurance. Their leaving emergency bills unpaid was not uncommon.

But according to you, they were not free riders (economically)?

They are punished when they are asked to get insurance before a big jump?

It strikes me as pretty silly to frame this as punishing “the uninsured” as a whole (as both you and Tyler do), when what it really seems to be doing is operating as a transfer from the richer uninsured to the poorer uninsured.

Except that the poorer uninsured for the most part had care anyway, in the form of charity. People keep talking about free riders; surely the poor were more likely to be free riders simply because they had less to lose. The Oregon Medicaid study, among others, demonstrates that a fair amount of the gain for the poor is fairly small.

Therefore, most of "what it really seems to be doing" is a transfer to the salaried middle and upper middle class, who previously helped pay for the charity care of the poor, from the middle and upper middle class in jobs without health insurance, along with some of the rich who pay extra tax on investments. The first group of losers is much more likely to include small business owners, contractors, doctors in private practices. The winners are much more likely to include salaried employees at large companies.

Surely it's not a coincidence that the largest effect of the policy is a transfer from Republican-leaning middle class to Democratic-leaning middle class.

Conchis is correct. There were, pre-PPACA, at least three relevant sub-groups of the uninsured:

1. Those who could have afforded health insurance but chose not to purchase it ("free-riders")
2. Those who wanted health insurance but could not afford it.
3. Those who simply could not find any health insurer willing to take them on.

PPACA uses the wealthier members of group #1 plus those who were already enrolled in individual health insurance to subsidize and help make insurance available to groups #2 and #3.

@John Thacker, I would love to see actual numbers on charity care pre-individual mandate but my impression from sources such as Steven Brill's Time article is that it was quite small. The more common scenario for those without money is that they would get charged full-freight at the hospital (much more than Medicare or private insurers) and the hospital would make efforts to collect on this debt.

Re. Charity - I am pretty sure that is coverage in the abstract, aspirational, sense, and not in the sense that every skateboarder in New Jersey or ski bum in Colorado knows a compassionate organization, or can find one.

Re: Except that the poorer uninsured for the most part had care anyway, in the form of charity.

This is so wrong as to qualify as deluded-- which explains why a certain segment of the body politic never wanted to do anything about healthcare, because they had talked themselves into thinking there really wasn't a problem. what charity care was available (much of it under EMTLA regs) was too little, too late for too high a cost.

Ricardo afford is a very, very squishy word. So squishy as to carry no meaning. We should avoid using it.

Just admit it, Europe/Canada systems are much better...It is really strange the so-called "leader of the free world" has these 3rd world problems...

But Freedom and American Exceptionalism...

think most ACA supporters who know anything about health care in other countries would admit this. We are doing what we can here. Hey, he's not the leader of the "free health care world."

ACA is a copy of the Swiss system. Hmmmm, looks like Switzerland is within Europe.

Also, its probably useful to take away a big lesson here: copying institutions doesn't always work.

That should suggest that Single Payer could easily have the same issue: copy Europe, don't achieve European results. In fact, I'm sure that is what would happen.

I think that Dan's comment is the truth.

It is objectively not true. Large, well-done surveys that actually ask the newly insured about this find that people really like having insurance and are using it. The majority of people say their new insurance is "good value".

I guess I trust a mathematical model behind a paywalled NBER paper less than actually asking people what they think.

http://www.commonwealthfund.org/acaTrackingSurvey/
http://kff.org/health-reform/report/survey-of-non-group-health-insurance-enrollees/

The newly insured are people who want to be insured and now can afford it due to subsidies. So naturally they are happy. The people who don't want to be insured but are required by the ACA to get insured, haven't been getting insurance since the law isn't being enforced. If they had been forced to purchase insurance, they would most likely not be pleased.

Of course, the funding scheme depended on the latter group paying in, so something has to give--lots of future unhappy people or the money will have to come from someplace else.

And before the ACA exchanges opened, a survey of all uninsured people showed that most of them were--surprise--dissatisfied with the health care system!
http://www.gallup.com/poll/179294/americans-satisfied-health-system-works.aspx

Now, millions more people who were previously uninsured have been able to obtain health insurance under the exchanges and they are very satisfied with it.

Those who remain uninsured are likely to still be--surprise--dissatisfied with the health care system.

The argument that the most uninsured have "lost" under the ACA is ridiculous on its face.

The requirement is to get minimum essential coverage, which you can provide for yourself if you attempt any self-employment work. www.selfinsured.org for more info.

This is likely to be incorrect. The majority of the still-uninsured are not well to do people choosing to go without insurance, but rather people who do not qualify for subsidies (e.g., immigrants and low income people in states that did not take Medicaid)

Of the people who've actually taken it up! That's not inconsistent with the results of this paper.

Even PPACA architect Jonathan Gruber, in the seminal article "Covering the Uninsured" (2008), argues that the assumption of paternalism (people suffer from a cognitive bias against insurance) is necessary to justify the mandate plan: http://www.nber.org/papers/w13758 . The Pauly et al. study proceeds from the assumption of rationality. That's really the core of the difference in their welfare results.

People who hate insurance also hate surveys. Few things get me angrier than spammers, telemarketers, and pollsters.

Nor should any of this surprise anyone. Passage required giving industry most of what they wanted and the costs are narrow but large in the form of uninsured that could not afford it, while the benefits are broad but shallow in the form of fewer free riders to support with most of the benefits passing to industry. The real test and greatest potential is increased cost control long term and that depends more on execution than on law.

The way to improve the law is to create health savings accounts independent of all insurance with tax exemptions, ban all insurance companies, and end all employer sponsored plans.

ACA is just a way for huge insurance companies with trillions under management to grab even more government money with no accountability. It makes everyone who is not an insurance executive worse off.

Nobody outside the .01% can afford to save enough money for the most expensive illnesses and injuries. HSAs must be paired with high deductible insurance.

OK, in a country where men attending elite universities are raping female students in droves, dentists are traveling halfway around the world to murder pet lions, security cameras are everywhere, fantastic locks to protect all forms of property are in continuous development, the threat to air transport requires partial nudity and Xray exams, DNA testing is the new fingerprinting and facial recognition software is the rage we're supposed to be concerned about the health of total strangers? Maybe that makes sense if you're a doctor, after all the owners of gas stations don't care where their customers go after they leave the pumps as long as they've paid for their petrol. The ACA is an industry effort not to just guarantee the financial success of the health business, it's meant to make that business the most important one in the country, the one to which everything else is subservient and dependent. The effort seems to be succeeding.

It concerns me that Americans aren't troubled by all the other issues you raise ... I dunno, perhaps it's a Canadian bias, but isn't provision of health care one of the most important things around?

isn’t provision of health care one of the most important things around?

Not really, at least if you exclude the really cheap stuff like vaccinations and antibiotics which people can get for free anyway.

Se: http://www.econtalk.org/archives/2007/05/hanson_on_healt.html

It has become clearer what has happened: members of various upper classes have achieved some notion of “universal [near universal] coverage,” while insulating their own medical care from most of the costs of this advance.

Really? This comment makes no sense to me. Every conservative has framed the ACA as a massive tax increase and huge wealth transfer to the poor. But now it is a tax on the poor from which the upper classes are insulated?

1. The analysis leave out the transfers to the newly insured via medicare (the part that "conservatives" most resent and have successfully resisted in many states).
2. Cost benefit analysis of policy has never been a "conservative" forte. They probably still think it is a major transfer from rich to poor.

No no it's a huge transfer from the young to the old (as usual)

This is all it ever was. With a little on the side for the insurance companies so they'd go along.

The old are on Medicare-- and yes, young people's taxes help pay for it-- though middle aged and near-old people are likely to be paying the bulk of that.

By charging older people three times as much for insurance as young people?

Yes, by charging 3x the cost of insurance for young people, which is results in significant subsidization to older insureds since their underlying claim costs are more than double that ratio. The way subsidies are calculated make this situation even worse.

Most folks are losers in insurance period. That's how it works. You buy insurance to guard against low-risk but high-cost events. You know this but choose to ignore it. I wonder why?

This isn't a study of actual premiums paid and actual losses. This is a study of what people are *willing to pay* for the coverage.

We already know these people weren't buying insurance. Why do we need a study to say that, yep, they didn't want to buy that insurance? That's why it's called an individual mandate rather than an individual polite request.

Just because you spend money on something (insuring risk) doesn't make you a loser?

Offer people a single payer system (any doctor, anywhere) without calling it single payer and they will gladly take it; call it single payer and people will reject it as socialism. The main problem with ACA is that it is built on a foundation of opposing forces and goals; hence, there will always be tension in execution and goals never quite reached. The main problem with economists who evaluate the costs and benefits of ACA is that all they can do is look in the rear-view mirror and add up the numbers, when the most important developments as the result of ACA are in the delivery of health care, developments that are revolutionizing health care, developments that aren't apparent to those who don't have eyes to see. I work with physicians in adapting to ACA and it amazes me how rapidly physicians are adapting to changes. Fragmentation (to use an economist's term) in the industry has made it difficult if not impossible to change the way health care is delivered, to make it more efficient, to make it more, well, modern. We think health care is dominated by technological innovations, but it's not. Sure, there have been many technological developments in medical equipment, but physicians' services have continued to be delivered the way they were delivered when Ike was president, no, when Teddy Roosevelt was president. Leaches and bleeding may have gone out of fashion, but not much else. ACA has jump-started health care into the 20th century, and if the knuckle-draggers can be held at bay, soon enough ACA will jump-start health care into the 21st century. Of course, along the way, the counters of numbers will keep us informed of their number-counting.

Doctors still use faxes instead of email and attachments. Don't mention smartphone aps. Here's a example of the nonsense;

http://www.nytimes.com/2015/09/22/upshot/trapped-in-the-system-a-sick-doctors-story.html

What became ACA was supposed to be about insuring more people AND making the system more efficient. Not enough was done on the second front. (I hope rayward is right and I am wrong.) Opinions may differ on which party's fault THAT was.

Just about every time I go into a doctor's office within ten minutes I wish I could fix their computer systems for them.

Offer people a single payer system (any doctor, anywhere) without calling it single payer

I want Ben Carson here and now.

From that quote it looks like the authors average the cost of being healthy with the cost of being sick. That will never work, in anything other than an exercise of abstract economics.

The healthcare problem was that healthy people never needed insurance, and then people with catastrophic illness or injury needed very good insurance.

Of course the average (healthy) poor-ish person has to pay more, and only a few (sick) people now get good treatment and avoid bankruptcy. That is the nature of the problem.

Take a look at the tables in the back. The authors break it down by income, health status, and income combined with health status. All previously groups of previously uninsured end up with lower welfare on average (whether they are sick and poor or sick and rich). The authors do ignore the possible increase in welfare that comes from the Medicaid extension by limiting the analysis to those with incomes greater than 138 percent of the poverty level. From what I understand, a large number of the previously uninsured are from below that line and a big chunk of the decreased uninsured number is due to those people signing up for Medicaid.

Looking back now, the arch conservative position was that poor people didn't need insurance and could rely on charity. It really should have been a small step from charity to free government funded clinics - were it not for a hurdle of ideology.

Short version of the paper: Prohibiting free-riding reduces the welfare of the free riders. Why is this surprising to anyone?

Bingo.

That said, quantifying that loss should be informative.

This would help in the same way as documenting that good/lucky drivers pay a higher burden for car insurance?

That might break down to a silly argument about who is good and who is lucky.

As in health insurance.

For one thing, the vehicle insurance market is competitive and it is possible to obtain liability coverage for less than $100/year. There are also a number of other ways to demonstrate fiscal responsibility, such as having sureties with real property or make a deposit with the comptroller (that cost $0/year). The ACA makes alternatives too cumbersome and the health insurance market is a huge scam.

Really? I can get a reasonable coverage for my market (like a million, for LA) for like $100?

I suspect you mean liability to a low limit, meaning another free rider

Actually, it is surprising. In the classic collective goods setup, prohibiting free riding raises the welfare of free riders.

Right. Part of the point is that the people who are worse off in this policy, the non-subsidy eligible generally in good health, weren't entirely free riding. They were accepting the very real risk of medical bankruptcy, and generally had quite a bit to lose. The people engaging in the most free riding were those who didn't have as much to lose, and who are understandably subsidy eligible.

The point of the policy was to shift costs (subsidizing the poor uninsured) from Democratic Party voting big company salaried upper middle class to Republican Party voting small business owners, contractors, private practice owners, etc. who are more likely to buy on the individual market, along with a portion of the rich and investors slightly above the double income upper middle class sweet spot. It's not even clear that the second group of losers has higher income overall than the first group, considering that the many of the worst hit are those just over the subsidy cliff.

Of course you could increase the size of the subsidies, though at some point it becomes as large as the former method of just charity care (especially as the layers of bureaucracy and slices of profit for the insurance companies kick in.)

The risk of being previously uninsured is perhaps not so big a deal for many. Going bankrupt is not a very large risk when you're broke.

Perhaps if you have 50k or 200k in the bank, or if you own a house, you can start to imagine all your money disappearing, or having to sell the house, to cover the cost of an accident.

More than 75% of the people who go bankrupt have insurance when they first get sick. If you have a 200k health claim, know that you will never work again. Either you have enough to sustain yourself for life and insurance won't make a lick of difference or you don't and you will be broke anyway.

Relying on the bankruptcy system is just another aspect of the free riding. It'd be interesting to see how the analysis would look if the model assumed that medical debt was like student loan debt and couldn't be discharged through bankruptcy.

I've often wondered if the need for the mandate could be eliminated by changing bankruptcy rules so insurance opt-outers couldn't discharge their medical debt. (I know this would be unworkable in the real world, but it still seems interesting.)

Actually, I would like to see this too. However, we also need to end all anti-competitive medical licensing, certificate of need laws, and pharmaceutical regulation. Practitioners should be required to either get explicit consent to any care given (including full disclosure of the cost) or be required to follow a policy specified by the patient (liked via RFID chip to a web site). Costs would drop 90% overnight without any change in outcomes.

Yeah, I am surprised that you think in bankruptcy hospitals get paid, and our premiums do not rise.

Which is more or less the case. The biggest difference between the amount hospitals get and what they say they want is underpayment by Medicare/Medicaid. Most people who go bankrupt have insurance but lose their jobs and can't pay their premiums or coinsurance/copayment amounts. Most of the rest would need to be 100% subsidized under Obamacare anyway. It is very rare that an independent person with a real job does not pay a debt legitimately incurred and is less than 2% of overall hospital costs.

Re: The point of the policy was to shift costs (subsidizing the poor uninsured) from Democratic Party voting big company salaried upper middle class to Republican Party voting small business owners, contractors, private practice owners, etc. who are more likely to buy on the individual market, along with a portion of the rich and investors slightly above the double income upper middle class sweet spot.

A weird assertion. The bulk of the taxes that fund the ACA are coming from the uppermost income groups (notably by removing the cap on the Medicare tax). Some of those people may be Democrats-- but some are certainly Republicans too. I suppose we could look up the break down. But where's the partisan bias in extracting money from some 900K/yr hedge fund manager to pay for a waitress' health policy?

The Republicans were put in control of the House and then the Senate primarily due to opposition to Obamacare. They have failed to make a good effort to do so. Why? Are they so afraid of being vilified by the media and the Democrats? Are they intimidated by another round of phony shutdown theater? Does Obama have dirt on the leadership via the NSA? See Hastert, Denny, for an odd but instructive case. Recall also that we would not have had Obama inflicted on us were it not for the release of his opponent's supposedly sealed divorce records, so blackmail is part of his bag of tricks. Actually, David Axelrod's because Obama is not smart enough to do such things; nasty enough, yes.

Trump is popular among Republican voters precisely because of his fearlessness and despite some of his dopey economic views. The Democrat strategy all along has to present the steamy dung heap that is Obamacare care as a done deal - live with it.

The Senate Democrats can and have filibustered, and even if that weren't possible, Obama has the veto.

They have made a good effort, even repealed a few provisions that were unworkable, but surely you can't imagine that they could get Obama to sign a full repeal. It's rather dopey to pretend that a repeal could be passed without a Republican President.

The bit about the debates seems a little ridiculous; surely a large part of it is the questions from the moderators?

Dude, liberals don't really like Obamacare. Some even see it as a welfare loss compared to the pre-Obamacare status quo, but... the pre-Obamacare status quo was really bad, and any movement in shifting US health care to a better system (ie, closer to single payer) is seen as a good thing. Liberals, probably including Obama, are not the people you have to convince here; it is the health industry and the middle class voters who opposed Obamacare for the reasons in the post. The health industry loves Obamacare since it is pouring more money into health care, so reform has some major political hurdles from that side (a nice way of putting it). However, the middle class voters in the post who are now worse off will more easily support a change closer to optimal health policy than they were under the pre-Obamacare status quo.

ACA is pouring money into health care, yet health care spending growth is lower than past decades' average, and lower than pre-ACA trend?

Question for you: what is "optimal health policy"?

Optimal policy for me would be single-payer that loads some risk onto individuals for efficiency's sake.

Liberals, probably including Obama, are not the people you have to convince here

Oh, so who is it then that is preventing the repeal from going through?

Liberals, probably including Obama. Repeal of Obamacare is worse than Obamacare staying, because that will mean a long-term return to the pre-Obamacare status quo, which is bad. Obamacare is not really much better and possibly worse, but it is probably a temporary bad that will hopefully be reformed into something reasonably good.

The butthurt is strong in this one.

Yeah, I'm not sure why he's so down about Obamacare. His first sentence sums it up. "The Republicans were put in control of the House and then the Senate primarily due to opposition to Obamacare."

The Democrats have taken a historically alarming shellacking over Obamacare. Furthermore, Obama has aggressively expanded the scope of Executive power. As soon as a Republican wins The White House, liberals will be severely limited in political power for at least 2 years, and most likely longer. Politically Obamacare was a huge win for Republicans and very rough for Democrats.

Exactly, just like gay marriage.

Losing so bad you're side is angry is not a win, unless you define win as soles getting elected.

Guess who tends to do that? Politicians.

But parties know they need to occasionally deliver the goods. Democrats are better at that. Republicans have believed they can do endless failure theater. They are now being caught out on that, and they will have major trouble. If your base doesn't turn out, as the anger fades, and becomes apathy, watch the Dems come back in Congress.

"endless failure theater" is good.

"If your base doesn’t turn out, as the anger fades, and becomes apathy, watch the Dems come back in Congress."

Well, that didn't happen in 2012 or 2014, but sure maybe 2016 will be a big win for the Democrats in Congress. Care to bet on it?

"Exactly, just like gay marriage."

No, I disagree. Gay marriage was a culture shift. The majority of the country is tentatively accepting of gay marriage. And gay marriage doesn't directly affect other people, it's quite possible to ignore it, if you don't like it. Obamacare effects everyone in the country and they can't ignore it.

Of course you are right about the politics of this, JC. Tea Party hypocrites who ran on opposing a Republican plan for health care won after tea party fanatics attacked town hall meetings in 2010 claiming "death panels" and all sorts of "socialist" disasters to come from adopting this Republican proposal. Doom was forecast over and over, including by you here personally repeatedly over a whole bunch of issues.

Deal with it JC,you were wrong wrong wrong wrong. Obamacare is not the ideal system, but virtually every single one of those disaster forecasts that you and your worthless pals here went on and on and on and on and on about were wrong wrong wrong wrong. And Obamacare is not even as socialist as what Friedrich A. Hayek supported in The Road to Serfdom, which was government supported universal health insurance.

You should apologize to all those you criticized on this matter, including those whom you joined with others to get really personal in your stinking ignorant hypocrisy. You need to admit you were wrong.

Deal with it, JC, Your many years fantasy/tantrum is over. It ain't perfect, but Obamacare works better even than its supporters forecasted that it would.

"Deal with it JC,you were wrong wrong wrong wrong.

Barkley Rosser, your comments were unkind. But I forgive you.

Huh? The GOP in the House has voted forty-eleven times to repeal the ACA. Guess what-- the Senate blocked them when the Dems controlled the Senate, and of course the president's veto loomed past that. What were you expecting the House GOP to do? "2nd Amendment remedies"? Civil War 2.0?

Re: Recall also that we would not have had Obama inflicted on us were it not for the release of his opponent’s supposedly sealed divorce records

Oh, I see, this is from tinfoil hat territory. Given the landscape of 2008, do you really think John McCain had a chance? I have a bridge in Brooklyn to sell you if you do.

Progressive support and gloating about Obamacare seems really strange (well, if it's not just from a source of base tribalism, anyway), as it just further entrenches the third-party system and makes moving to single-payer (presumably what they want) even harder. Obamacare may be a better way to do third-party medical payments than before, but that's not exactly an accomplishment.

Obamacare is only really good in opposition to the old "let them find charity" argument, and that is the one that is well dead.

Why not dance with the devil and adopt broad-based public health care?

It's cheaper by any possible measure (than the American system) and delivers better average results for basically every indicator when compared to other wealthy countries.

The US already is responsible for most of the healthcare spending in the US. Medicaid, Medicare, and the Veteran's programs have a horrible track record in terms of efficiency, and the US implementation of single payer would be even worse. If we want to copy a useful system we should copy Singapore.

I oppose Obamacare, but let's check for confirmation bias. What do Krugman or DeLong or Kruger have to say about this study?

I supposed I should evaluate the study for myself, but 1) that would take a lot of effort, 2) I'm not really qualified.

It sounds like the paper is basically saying there's a slice of relatively well-off (>250% of poverty level), healthy uninsured who were arguably better off not having to buy health insurance. This is not exactly news to anyone who's been following along. Krugman has written about it on his blog. Search Google for "Krugman Obamacare losers".

If conservatives have basically accepted that Obamacare is here to stay, why don't they now start being a little more constructive? There are tons of ways to improve the medical system that are essentially conversative-friendly supply-side reforms -- e.g., allowing nurse practioners to do the work of doctors, allowing in more foreign doctors, reducing the regulatory burden for new drugs (admitted, that's a little more complex), maybe trimming down drug patents (again, that's a bit more complex), etc. I'd totally sign up to support that kind of stuff! C'mon guuuyyys **music starts playing** we are not just a collection of blue states, and red states, but are and always will be, the United . . . . [etc. etc.] ;-)

You're joking, right?

You do know that the GOP wanted to pass reforms to the ACA that were word for word the same as Obama's executive actions and Obama threatened to veto them.

Obama won't let them near suggesting good ideas, dude.

(and yes, they seem to be in his thrall.)

Interesting. Just curious... do you have a link?

We also still get the usual progressives I know complaining about lack of healthcare in the country.

The one silver lining I wanted was for the sob stories to end.

Nope.

I'm pretty sure we could have gold-plated single payer, and there would still be progressives on my FB sharing memes about someone who didn't get healthcare and its all because we're too capitalist.

Or maybe like the VA scandal, the progressives would shut up then, even as actual patients really did not receive care.

Disclaimer: there are many smart progressives (you may be one) who do not do this, but many, many I know constantly share memes like this. My favorite was the story about the guy who robbed a bank to pay for his healthcare. Oh, the beating of breasts about how bad America is on that one. Turns out he could have gotten Medicaid, or visited 3 free clinics within a few miles of the crime. This makes me suspect the issue is NOT healthcare, but something else going on...signalling to show how much they care, maybe?

When Obamacare was first proposed, I guess I was not really surprised that most people, and even most economists, did not understand what it was or how it would work. At this point, the willful lack of understanding displayed here and elsewhere is pretty sad.

Let me say this again: (1) Obamacare is insurance, it is not healthcare; (2) insurance protects the insured from the financial consequences of various types of risk, it does not prevent the risks from occurring, it does not directly address the risks after they occur (fire insurance does not actually prevent fires or put them out or directly help repair or rebuild the damaged property) it only mitigates the financial consequences; (3) by and large, the pre-Obamacare "uninsured" do not have significant financial assets to protect; and thus, (4) the vast majority of them cannot benefit from Obamacare whether or not they become sick and whether or not they had pre-existing conditions. Under the individual mandate, young, healthy, poor, people with no assets are being "taxed" to lower health care costs for the benefit of middle aged wealthy people with assets.

Obamacare did not increase access to healthcare. On balance, it reduced access to healthcare. If you want to increase access to healthcare, you need to build hospitals, produce more medical devices, train more doctors and bring them into practice, etc. Obamacare did the opposite. It placed added financial and regulatory burdens on the healthcare system, increased taxes on medical devices, etc. On net, the poor and middle class had more access to healthcare at lower net cost before the changes made by Obamacare were instituted.

None of this really matters, however, because Obamacare will collapse of its own weight as soon as the subsidies for insurance companies are removed shortly after the 2016 election.

They knew at the time this was going to me nothing more than an income-transfer program.

http://www.brookings.edu/research/papers/2014/01/potential-effects-affordable-care-act-income-inequality-aaron-burtless

And it has been just that. I think the strongest proponents find that to be a feature, not a bug.

"I fully understand that Obamacare has survived the ravages of the Republican Party, and it was barely attacked in the recent series of debates, and thus it is permanently ensconced, and that no better politically feasible alternative has been proposed. At this point, the best thing to do is to improve it from within. Still, there are good reasons why it will never be so incredibly popular".

Hahaha, the flaw in your reasoning is that you assume the Republican party is an effective political party. hahaha good one.

Sorry Tyler, creating models and doing calculations does make a study scientific. There are numerous assumptions between data and the claim; most notably that dollar has the same utility to all involved.

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