Megan McArdle on the collapse of Obamacare

Her earlier prediction:

Obamacare would not, and could not, be the program that had been promised or intended. It had already failed to deliver on key promises for coverage, affordability and of course, the infamous promise that “if you like your doctor, you can keep your doctor.” It was also dangerously unstable, requiring steady executive intervention just to keep the program from collapsing. I argued that these executive interventions, enthusiastically supported by the law’s proponents, were setting a precedent that would eventually be used against it. Worried that health care was too hostage to the vicissitudes of the markets, Democrats had instead made it the prisoner of politics.

“Essentially they’ve made it so that Republicans can undo two-thirds of this law with a stroke of the presidential pen,” I said at the close of my opening statement. “Obamacare is now beyond rescue. The administration has destroyed their own law in order to save it.” Four years later, we are watching those dominos fall.

Here is the full Bloomberg piece.


The Democrats claim to be in favor of amending the ACA's flaws, but have not offered any meaningful changes in proposed legislation. The last example I could find (see below) reads like an extension of the then-current status quo.

Health insurance does not lead to better health outcomes. Health insurance may, however, mitigate medical bankruptcy. Catastrophic plans would meet this goal without greatly adding to the mess created by federal health law and regulations.

"Health insurance does not lead to better health outcomes."


But Oregon, which was random, showed differently.


From the link:

---One fair thing would be to simply say that it’s inconclusive, full stop. It tells us nothing about the effect of Medicaid access on diabetes, cholesterol levels, or blood pressure maintenance. I’m fine with that interpretation.

---Another fair thing would be to say that the results were positive, but the study was simply too small to tell us if the results are real.

---Or there’s a third fair thing you could say: From a Bayesian perspective, the Oregon results should slightly increase our belief that access to Medicaid produces positive results for diabetes, cholesterol levels, and blood pressure maintenance. It shouldn’t increase our belief much, but if you toss the positive point estimates into the stew of everything we already know, they add slightly to our prior belief that Medicaid is effective.

---But you can’t say that the results are disappointing, at least not without a lot of caveats. At a minimum, the bare fact that the results aren’t statistically significant certainly can’t be described as a disappointment. That was baked into the cake from the beginning. This study was never likely to find significant results in the first place.

No it didn't.

That improvements were not statistically significant in many area is disappointing, but given the nature of the analysis done, unsurprising.

The focus on statistical significance is troublesome. We can have very significant differences with small to very small effect size. The real payoff is finding a way to get big improvements (effects) with the relatively low costs. Findings of statistical significance tell us little about how effective the treatment is and whether or not it is cost effective

Because bankrupt and closed hospitals are the best outcomes.

In ability to see any doctor is a great outcome.

Bleeding out in the street from accidents is the best outcome.

No one should ever be paid to provide medical care.

It is disasterous that SSDI beneficiaries numbers are going down because older workers can get medical care and continue to work thanks to medicaid expansion under Obamacare.

Things were so much better when Bush was president and employers were bitching about 10% increases in health benefit costs and pushing higher deductibles and higher employee coverage payments onto employees.

The GOP has been promising free lunch health care for decades. Trump flat out promised free health care and unrestricted access to the best and most expensive doctors. At least, that's what I heard him say.


The GOP and Trump have failed to deliver free lunch health feast if steak and lobster, and it seems to be just a handful of moldy biscuits for 300 million people.

Did you just put "No one should ever be paid to provide medical care" and TANSTAAFL in the same post?

ACA did two things: indirectly took control over people's health insurance and grossly expanded Medicaid. Neither of which enhanced anybody's health/wellness or health care experience one bit.

By executive order (you loved it when Obama pulled it) My President Trump ended the unconstitutional (without Congress) payments of taxpayer money subsidies (stealing from your neighbors with the government as middleman) to other Americans for Cadillac (full of mandates) health insurance plans.

This is only the beginning. Fasten your Trump Derangement Syndrome Belts.

Before ACA millions of people were dying without care, but 80% (consistent polling) of Americans were happy with their health care insurance arrangements. If it was such a dire crisis, why did the Dems pass it (without reading ACA) in 2010 and postponed its effective dates until 2013? Afraid they'd lose the 2012 election. They got blasted in 2104 Congressional elections.

You get sick, you go to a hospital and you will be treated. They don't deny treatment. If you can't pay, they deal with it.

Right, they got treatment and everyone who bought health insurance indirectly paid for it.

Probably not much real difference than having the tax payers pay for it directly.

"You get sick, you go to a hospital and you will be treated."

This is not true; it applies to emergency care only. If you are bleeding, they'll stitch you up. But if you have cancer, they'll just send you home.

You get sick, you go to a hospital and you will be treated. They don’t deny treatment. If you can’t pay, they deal with it.

I will state it more strongly than Ricardo did. This is an outright lie, perpetrated and deliberately spread by the right. Your willingness to be a party to the disinformation campaign does not speak well of you.

Spencer's idea could be tested.

Also not everyone helps pay for it. That's important

What an ass - you are the most depressing, pathetic commentator ever.

>If fewer people are dying, that is almost certainly because diseases are being better treated, managed, or prevented—because of improved health.

Transparent question-begging. The example of the Amish ( is sufficient to show that this is nonsense.

The Democrats claim to be in favor of amending the ACA’s flaws, but have not offered any meaningful changes in proposed legislation. The last example I could find (see below) reads like an extension of the then-current status quo.

Obamacare is not hard to fix because it simply does not have many problems and the few that does are not major ones. Yes it is hard to get a lot of competition for insurance in rural areas. That leads to few providers and high premiums. Put a little bit of money behind Medicaid expansion and cost sharing with insurance companies and 50% premium increases turn into 5% ones.

Democrats would have worked with Trump on ideas 'for great health care' but even a modest bill to stabilize insurance markets and keep people from being kicked off coverage was side tracked because Republicans insisted using their remaining time in September trying to get the votes on yet another version of "let's charge people $50,000 a year for pre-existing conditions and pretend it's fixing health care"

"Stabilize markets" is NPR/NYT speak for "spend tens of billions more dollars to lower premiums, because original projections of young people joining were Democrat lies".

No problems? Nothing that a Single Payer couldn't fix - that is your solution?

There is no evidence that the Democrats would have worked with Trump on anything except Single Payer.

You seem to have missed the obvious - the Republicans do not want changes to Obamacare. Their voters do. Their voters are being tricked but not by the secret Koch-agenda of the GOPe.

The central conceit is that Republicans have no solutions that actually stabilize or expand coverage while reducing costs, particularly out of pocket costs, which are the two "problems" they've railed against Obamacare for. They were exposed as not having any ideas that almost anybody except rich Republican donors like, time and again this past 6 months.

As Boonton says, fixes to the ACA are easy and obvious. Those easy fixes don't get Republican support because 1) they don't actually care about health care policy, 2) prefer tax cuts to helping the poor and near poor access health care, and 3) they lied about how bad Obamacare is for years and so they can't possibly fix it. So they end up in this situation where they can't actually repeal the the law because it would be disastrous and they have no replacement. They can't do anything except fail.

Easy and obvious = spend more $$$ but lie about it.

Those easy fixes don’t get Republican support because 1) they don’t actually care about health care policy, 2) prefer tax cuts to helping the poor and near poor access health care, and 3) they lied about how bad Obamacare is for years and so they can’t possibly fix it.

What a truly horrible human being you are Jan. Any evidence for the first two claims?

The voters do no think they lied about the the third. This is why the Democrats are losing everything everywhere.

So Much For Subtlety ask for "any evidence for the first two claims". How about:

“Well, I’ve been doing it for about a month. I thought everybody else knew what the hell they were talking about, but apparently not.” Lindsay Graham

"Nobody knew health care could be so complicated." Donald Trump


How about Republican behavior and (chuckle) proposals? That's all the evidence you need. Where exactly is Trump's cheaper, better, plan?

Easy fixes are to be brutal about the mandate like Switzerland.

Another is to be less generous.

Democrats know this but they want the GOP to be Mr. Grinch.

Cmon Dems stop shirking. State run care is your idea and it requires a Mr Grinch

But none of that matters until you are willing to tell Doctors they will be driving Honda Civics in the future and not Mercedes and BMWs and Lexus’s. Every dime that gets paid into health care system eventually gets paid out to someone. Until we find a way to reduce what those “someone’s” get this system is unsustainable

If it was so easy to fix, why wasn't that done just last year?

It seems logically that health insurance would lead to better health outcomes. If a PCP visit doesn't cost so much, I'm much more likely to see a doctor early about an illness and treat it cheaply.

Likewise, catastrophic-only plans aren't a panacea because I'm waiting till the last possible minute to get care. Shouldn't we try to incentivize cheap preventive care over expensive emergency room care?

Should we lower automobile ownership costs by mandating car insurance include free quarterly oil changes?

The government doesn't swoop in and pay if your badly maintained car breaks down. They do if you go to the emergency room and can't pay for it.

The assumption that getting health care is always a good thing is part of the problem. Over 100,000 people die each year due to infections and malpractice that happens in hospitals

Not true. The methodology in that study was awful. The Hopkins study was even worse.


"Preventive care" means exercise daily, don't smoke, don't be promiscuous, drink moderately if at all, eat a balanced diet, and don't use drugs.

Health insurance may, however, mitigate medical bankruptcy.

So fewer people will become bankrupt because of high medical bills. More people will become bankrupt because of high taxes instead. Not to mention a lot of businesses that will never get off the ground - remember Europe's woeful record on start ups. Which makes America greater?

Personally I think it is unacceptable that life insurance costs more for smokers. Just because they die earlier or something. So I think it is only fair and reasonable that the government mandates all the non-smokers share the costs so that smokers get the same pay outs that non-smokers do.

Unfortunately Mitch McConnel wants to keep kowtowing to Obama and not repeal the damn thing like the President asked.

McCardle isn’t wrong; but there is nothing special about ACA in her being right. Enforcement of the entire Criminal Code and the existence of the military as an effective organization depends on the President not choosing to undermine the purpose of the law. Prosecutors are not compelled to prosecute any particular violation of law, nor indeed to prosecute any violation of a particular law. The President can dismiss generals and as commander in chief can choose actions that could be intentionally ruinous.

Any law that does much behind naming post offices needs substantial cooperation from the executive and Obamacare isn’t new or special for that.

Time and again, we see that you can believe in and work for democracy, or you can believe in and work for free markets. McCardle reveals a deep animosity toward democracy.

You can also do both, or neither. #Resist is a big fan of neither.

Rightly so!

Democracy is two wolves and a sheep voting on what's for dinner.

The pre-historic instinct for peaceable mutualistic cooperation is stronger than the instinct for violently-securing alpha status, though both tendencies exist.

We glimpse this in times of acute crisis in which the comforts of civilization are superseded by immediate want. People are far more likely to organize themselves collectively for mutual aid and use eventual surplus for the group's advancement rather than immediately organize themselves into exploitative packs. (These crises are often paradoxically understood to be the most liberating time in modern people's lives, for we are forced back into a deeply gratifying mode of caring about others as much as ourselves).

The immense efficiencies gained by beaurocratic and material technologies allowed us to prosper and yet experience profound alienation from our organic collectivism. In our alienation, we are easily drawn into identifying with "imagined communties" that impose on us and occasionally relieve status anxieties. Just as we engage with entertaining stories yet experience real emotion, we identify with imagined communities (nation, race, gender, guild, etc...) yet experience real status anxiety and its resolution.

The job of visionary politics is to first recognize that we can never win by identifying ourselves with artificial, abstract tribes and will always long for sincere communal connection. We must use all our intelligence and insight to build the best of both worlds: to continue to enjoy the material gains of technology, but enjoy them in small, egalitarian, collectivist communities that resonate with our pre-historic social natures.

All is supremely well. We are quite possibly a light unto the Universe! And there is much work to do.

Tribe: On Homecoming & Belonging

This book can red-pill u for sure.

I'll give the book a shot. As a narrative, I think it only speaks half of the truth. Crises are probably liberating, but not because of kum bai yah. I think it sheds the artificial parts of us, which at times are the selfish and individualist parts. At the current time, I think we have a lot of false generosity, which is what I accuse a lot of socialism to be - yes, I want to poor to be fed, I just don't want to personally feed them, therefore let's use the public purse to do it.

I think the next crisis is looming, and there are a lot of fake saints out there. Shedding the lies and coming to grips with who and what we really are, and are really capable of, is scary... but in truth there is freedom.

... laws are not sacred wisdom and guidance handed down by god(s). Most Congressional laws are foolish nonsense dispensed by crass politicians. ObamaCare was a blatant disaster from its inception, even if Obama himself had remained President permanently.

McArdle restates the obvious. Letting politicians run the American health care system is ten times worse than any imagined failings of private free markets.

Forgoing medical care for lack of insurance is a blatant disaster. Facing unnecessary financial ruin because of a cancer diagnosis is a blatant disaster.

Let's practice:

Hurricane Harvey: blatant disaster

Beaurocratic complexity of Obamacare : not a blatant disaster.

CA wildfires: a blatant disaster

National debt: not a blatant disaster

Iraq war: a blatant disaster

The post office, DMV, and VA: not a blatant disaster.

Makes sense, right?

Hurricane Harvey damage in August - roughly $150 billion (midpoint of multiple estimates)
CA wildfires - roughly $5 billion worth of homes damaged; exact value hard to find

Interest expenses on the national debt in August - $30.3 billion (
ACA bureaucracy in August - roughly $23 billion ( estimates it at $273.6 billion per year)

Hurricane Harvey accounts for roughly seven months of ACA bureaucracy or four months' interest on the national debt. California wildfires are small in comparison to government waste.

National debt: not a disaster. Not yet is not the same as not ever.

Comparing forced insurance that is really high priced prepayment that won't be cost effective for many until they're 40 or 50 to the chance of going bankrupt while still getting care, there isn't so much to choose from actually. If people could actually get simple medical insurance it would be a different situation.

There's an idea of a Megan McArdle, an abstraction. But if you look her in the eye, shake her hand, and look at her bowtied husband she's simply not there.

And let's not forget that giant dog she has. There's something not quite right with people who have big giant dogs. Kind of like people who own assault rifles.

Like, there's something not right with you man! Leave Scooby alone!

The president's job is NOT to carry out the "purpose" of the law, only the law as it is written. President Obama was forced to resort to all sorts of dubious executive actions (e.g., section 1402 subsidies) to carry out the law's "purpose." Let the rotten law collapse on itself.

Is it the president's job to "make things fail?"

The hole is obvious. It has been dug by many of you, and Trump.

Neither President Trump nor the Republicans in Congress have any obligation to lift a finger to make a law that all of them campaigned against work better if they are not so inclined. That's what elections are supposedly all about. So there is nothing wrong if President Trump simply undoes all of President Obama's dubious fixes and hopes that it will accelerate the failure of the law. And if you are going to complain about executive action that goes beyond undoing what President Obama did, then you had better be prepared to condemn the precedents set by President Obama on health care and immigration (talk about making current law fail that was even slapped down by the judiciary).

I am still laughing.

There was never a rule in government or anywhere else that you have to sink the boat before you fix it, crash the car before you paint it, burn down the house to get the termites.

But you nitwits think you can sell that a Republican President had to firebomb healthcare for actual citizens (in his supporter demographic!) in order to force a Republican Congress to act.

Republicans fighting Republicans by punching voters.

What a winner!

Only a "nitwit" would assume that I am eager for Congress to do much beyond repeal (block granting Medicaid is their best idea, but people have been kicking around that idea since at least Reagan). If repeal can be accomplished by the law itself falling apart along with nudge from the president and/or Congress, then I'm content. Gridlock can be a wonderful thing. Cutting benefits is rarely popular, so tell us something that we don't already know.

What percentage of voters support straight repeal? In July it was 36%.

May I chuckle at the general, and repeated, strategy of doing unpopular things, leading up to 2018?

I'm not convinced that this carries the same risk as repeal. Congress had to act to pass a law to repeal, and that created a circus, lots of news, and eventual failure. Trump's executive order will be out of the news cycle in a day or two, and what most people will actually notice is just he higher insurance premiums. They might even blame Obama for that.

There will be some short term winners who buy cheaper but poorer insurance.

It will matter a bit what insurance companies say if and when they raise rates. Or terminate more plans. But certainly Democrats have a button to push which they didn't have last week. It is no longer all on them.

If you want to talk about political campaign strategy rather than law and policy, be my guest. President Obama and congressional Democrats passed the ACA knowing that it wasn't very popular at the time, so I assume that you were also chuckling at the Democrats in 2010 for passing a law that resulted in their shellacking.

I was in the "ACA is a stopgap before single payer" (and preferring vouchers) camp. That currently polls higher than full repeal, so there is a chance.

But you are right, the Republicans should be thinking about that example very hard.

You believe ACA was a policy designed to intentionally fail thus creating "need" for single payer? Wow, you socialists are Machiavellian. Although when you don't believe in morality, it follows that you would commit great evils in pursuit of your desires for power. You are Stalin's children.

No, Thomas. Another bad guess.

The ACA was an improvement in what was before (why it is so hard to repeal) but not a beautiful or elegant solution.

By the way, I think I remember a Thomas who was for single payer ..

The president’s job is to adhere to the constitution, and faithfully execute the laws.

If these are in tension, it is the president’s duty to uphold his sworn oath to follow the constitution.

The End.

If the president must break the constitution to execute a law, then the law is unconstitutional or the method of execution is unconstitutional. Prosecuting federal crimes is executing the law. Breaking into criminals’ homes is a violation of the Bill of Rights, even when used to “execute the law.”

No, it is not acceptable for a president (bush, Obama) to use executive orders to usurp authority from Congress. Whether it’s republican or democratic ends that would be served, it is still unconstitutional.

The payments are not constitutional. Congress can pass a law or not to fix it. Hopefully they do.

Simple question. Will any Trump voter *feel* harmed by today's action?

There is no replacement. Literally nothing from Republicans that address their own criticisms of the law, as we've seen the last few months. You may wish the ACA to collapse out of spite, but it will be much worse for a whole ton of people, and that is why what Trump is doing is supremely unpopular with the public, similar to sentiments about repeal without replace.

I'm content with repeal not out of spite but because I reject the whole goal of guaranteed, universal, gold-plan health care. It continually amazes me that on a libertarian-leaning blog that the left finds it outlandish to see people actually holding libertarian and conservative positions. The failure of Republicans is that they have yielded too much rhetorical ground to the left so they end up with Trump promising bread and circuses that he cannot deliver. Thus the best feasible scenario is de facto repeal followed by policy stasis.

You can believe that the richest country in the world has no social contract to ensure its people have access to health care that can't bankrupt them, unlike literally every other wealthy nation. As R's haven't pointed out, the status quo is not in fact universal and far from gold-plared, but it's a lot better than it was. Anyway, I don't agree with you, but fair enough.

I'm saying we should all recognize that the politicians who opposed and railed against the ACA all these years were insincere about why they didn't like it, what they could do instead, or both. I assume you don't for these clowns, because they embody everyone's worst perception of "politicians."

The problem with people like Jan is that they lie about how much universal health care would cost the US and they don't care anyway! It could cost 50% of GDP and these fanatical socialists would be happy to starve to achieve their moronic, symbolic goals they've been told to value.

It has to burn down before the Democrats will come back to the table.

"there is nothing special about ACA in her being right"

I think you're missing her point -- she's not saying just that what's done can be undone, she's saying that PPACA specifically was incomplete, and it front-loaded the benefits while pushing the costs and difficult decisions out a few years -- it needed a future administration to actively continue to make it work, not just to not kill it.

What an unrealistic expectation .. that future Administrations would want something that worked as well, or better.

Surely they should have expected "burn it down" and "nothing matters anymore" as a political philosophy.


There's an idea of Megan McArdle, an abstraction - but when you look into her eye, shake her hand, and look at her bowtie wearing husband she's not really there.....

Just because McCardle can't remember back 8 years doesn't mean that her readers can't (or maybe she's right and they can't). In terms of involving Republicans (particularly Senators in the drafting process) and accepting Republican amendments, it's hard to fault the Democrats for not trying to be bipartisan. It's also worth noting that Democrats only had 60 votes between July 7, 2009 (when the Republicans finally agreed to seat Al Franken) and August 25, 2009 (when Kennedy died), and then again from September 24, 2009 (when his successor was appointed) until January 3, 2010, when Scott Brown was elected. McConnell decided it was better for his party to require Democrats to have 60 votes for anything they wanted to, which seems to have worked for him whatever the cost to our country.

The right wing and the GOP have had to rewrite history to claim Obamacare was passed with only Democratic votes.

Arlen Specter was never nominated nor elected to Congress by Democrats.

Joe Lieberman was booted out of the Democratic Party by Democrats and he was elected by Republicans and independents, defeating the Democratic nominee. Then he joined McCain in his campaign for the White House, based on a platform of eliminating all group health insurance plans and mandated buying of private individual insurance policies, plus lots of nation building like in Japan, Korea, Europe, by military occupation. Ie, a minimum 50 years of large military occupation of Afghanistan and Iraq.

And Obamacare structure was defined by Republican Mitt Romney who planned to use his health reform solution as Massachusetts governor as his ticket to the White House.

The only solution the GOP had before 2009 was Romney care that became Obamacare. Once Obama embraced the GOP solution, the GOP had no solution because everything they proposed ended up being Obamacare or government single payer.

Note high risk pools created by States for those denied private insurance devolves into single payer. Only the healthy who need no insurance will be offered insurance that will pay nothing in exchange for insurance premiums. Everyone else goes into the government run high risk pool.

Actually the GOP did have a solution, not changing anything. The old system wasnt perfect by any stretch, but there wasnt some exigent circumstance that required a total overhaul either.

The many millions more uninsured people than there are now was kind of an issue, but if you weren't one of those people you probably didn't notice or care.

Obama was elected, in no minor part, to deal with a failing healthcare system. I remember my last policy pre-obamacare reforms, which was the best option my employer offered. It had a lifetime maximum of 600k, 20% hospital counsurance, $50 primary care provider copayments and an 8k deductible. All for about $700 a month for two people. Sure, it was affordable, but it was useless for little things, useless for big things, and crippling in many points in between. I had a coworker quit because his child had cancer, and there's no way he could afford the treatment under those terms.

Now, one doesn't have to change things the same way Obamacare did, but under Bush, incentives were all towards prices spiraling out of control anyway. Going back to the old legislation will lead to the white middle class asking for reforms in less than 2 years

Obama was elected because of the Iraq war and the financial crisis. Full stop.

When you elect a Democrat you inevitably get a push for socialized medicine, but swing voters in 2008 didn't care in the least about that. They were angry at the Republicans about Iraq and about the economy, and so they voted for Obama.

There's no question that Republicans (and Koch minions) have been correct all along that Obamacare would fail. I have to give them credit. Just like how Islamists predicted that United Airlines Flight 93 was not flightworthy. And it wasn't!

As someone who clearly dwells in a different world than you, let me try to build a bridge. Yelling at Koch does nothing to make your case look convincing, any more than I'm impressed when a RWNJ yells at Soros or The Zuck. It carries equally little weight and serves only as a 2MinuteHate for either side.

Nobody has been more aggressively trying to sabotage Obamacare than the Koch brothers. For this and many other reasons, they are extraordinarily evil and should be condemned at every opportunity. I happen to think Soros is horrible as well. His funding of movements like BLM has also caused a lot of deaths.

For the Left exercising your Constitutionally protected rights to protest is always sabotage or wrecking or something.

Well, yeah, I'm not a fan of anyone who's so rich that they feel the need to throw money at politicians, Koch or Soros. I just don't find them to be ebil debbils that scare me.

It's bad ideas that scare me, not fools with too much money.

Ok, so private health insurance can never work.

Medicaid For All, government single payer health care is the conservative solution?

Or is the conservative medical treatment a signed organ donor card to get a gun with a single bullet and instructions on the best angle to blow out your brains?

Obamacare was one of two GOP proposals as of 2008. The other one was eliminating all group health care plans and mandating everyone buy individual health insurance policy from private insurers regulated by the Federal government to be portable everywhere in the US so changing jobs or moving does not require changing insurance. Ie, McCain's plan was cancelling almost everyone's health insurance and forcing everyone to deal with the doctors and hospitals their new insurers let you use.


-1. I'm sorry, but you're telling me that legislators have an obligation to vote for and then do everything they can to hold up a program they think is bad???? Democrats could barely get enough Democrats to vote for the darn thing! Massachusetts voted for a Republican because of it! I have to admit that I was somewhat curious to see what would happen when the largest domestic policy change since Medicaid and Medicare passed without bipartisan support. The results aren't very surprising. Democrats should have seen this coming and adjusted their plan accordingly, but "elections have consequences" is what I've heard. I can't blame them for not foreseeing a near future with Trump as president, but they should have at least figured that a Republican of some kind would have a decent chance of winning in 2016. I write all of this as a Never Trumper, by the way.

They have an obligation to do something that addresses their central criticisms of Obamacare these past few years. Not one proposal from Republicans actually would improve the healthcare market on the very metrics Republicans have complained about it.

Also, not sure what you mean by get enough Democrats to vote for the darn thing. Every Democrat voted for it.

They have an obligation to represent their voters. If they fail in representing their voters they can be voted out of office.

They do not have an obligation to shovel more money into a law that they did not and do not support. They do not have the votes to change the law. So it appears the future is either a mostly broken individual insurance market or a death spiral.

If democrats wanted a 10,000 dollar fine for not signing up for insurance they could have passed it. If democrats want to start a massive non profit to shovel money at people to pay for their insurance they are welcome to. I would even donate.

My guess is stasis and dysfunction, a democratic congress will eventually add a public option and the individual insurance market will implode.

What they told their voters is not that millions will lose insurance and premiums skyrocket. As an example, do you remember what Trump said about what his health plan would do?

Most voters (of all stripes) do not want Republicans to DePaul repeal the ACA without a better replacement. The polling is clear.

Though I will say it's pretty obvious that the big money R donor class does want straight ACA repeal. But that's strictly a taxes and costs thing for them. The access to health care side of the equation does not register for them.

Jan October 13, 2017 at 7:35 pm

What they told their voters is not that millions will lose insurance and premiums skyrocket.

It is true that Obama and Pelosi did not tell their voters that millions would lose their insurance and premiums would skyrocket. In fact I am pretty sure that they told their voters the exact opposite. What this has to do with Republicans I do not know.

Most voters (of all stripes) do not want Republicans to DePaul repeal the ACA without a better replacement. The polling is clear.

For some definition of "better".

54 Jan October 13, 2017 at 7:38 pm

Though I will say it’s pretty obvious that the big money R donor class does want straight ACA repeal. But that’s strictly a taxes and costs thing for them. The access to health care side of the equation does not register for them.

On the contrary it is clear that the big money donor class loves Obamacare and that is why the COPe is refusing to repeal it. That is why McCain killed it. It is ordinary Republican voters who are sick of the big money donors and their bought-and-paid-for lackeys which is fueling Trump. And why wouldn't the big money love Obamacare? It is giving the big corporations unfettered access to tax payers' money! It is like defense contracting only better.

I think Massachusetts voted for a Republican because the Democrats ran a terrible candidate.

Long term, I think that the republicans will regret letting ACA fail. Not because it is a great program, but because its failure will lead to Democrats pushing for and likely passing a single payer plan next time they have both chambers and the presidency.

The true fixes for the ACA require being stingier and meaner. If Deomxrats want to save it they can sack up and admit that

I'm not commenting on the merits one way or the other. I just think this is a path that has a fairly high chance of leading to single payer.

In any case, the Republicans control the house and the senate and the presidency right now. If they wanted to they could make those changes without a single Dem vote, if they just get rid of the filibuster.

It seems pretty clear that the Republicans are not at all united wrt reforming/repealing Obamacare. Nobody actually knows a good way to fix healthcare in the US in a way that doesn't break the bank, makes sure everyone gets covered, and is even remotely politically workable. Obamacare was the closest the Democrats could come, and it was a mess.

If Obamacare collapses under Republican leadership, they're going to get the blame from voters. Whether the seeds of its ultimate failure were planted by Obama or Trump won't matter.

Though I agree that Democrats ran a bad candidate, we're talking about Massachusetts!!!! There was something more going on than just a bad Dem candidate vs. a good Repub candidate. How many heavily Republican and heavily Democratic states and districts have elected low quality Congressional candidates from the dominant party? A lot. I don't think that's a sufficient explanation for the outcome in the special election. I don't even think Scott Brown is that great of a candidate. He looks good. He drives around in a red truck. Am I missing something else?

Of course, McArdle is peddling nonsense (her specialty, and, to her credit, at which she is very good). Unless and until everyone is subject to the same risk pool (that's what doomed the ACA marketplace, where high risk insureds predominated), there will be those who game the system, including, especially, insurers. But remember this adage: be careful what you ask for.

...... ACA has absolutely nothing to do with "marketplace" or "insurance". McArdle is slow on the uptake but much faster than ACA supporters

Because markets only exist in a system of pure-Ayn Randian free enterprise.

ACA is a bastardized redistribution policy requiring hundreds of billions of dollars in government subsidies designed to look like a marketplace, with a few bennies thrown in to get bare minimum political support to pass. It doesn't take an Randroid to see this


And Republicans have literally not proposal that addresses their own critiques of the law. They lied and lied again.

Honestly Jan, we are just going to repeal Obamacare, but if you like your doctor you'll be able to keep your doctor, and if you like your insurance you will be able to keep your insurance. You should have no problems swallowing that big load for a second time, right?

Jan October 13, 2017 at 5:50 pm

And Republicans have literally not proposal that addresses their own critiques of the law. They lied and lied again.

That is not fair. They have put forward half a dozen proposals. All got rejected. Since then they have been open - they want to repeal and replace. They have never gone into an election with a specific concrete proposal about what they would replace it with. Not even Trump did. They just said repeal and replace.

As it turns out they don't really want to repeal. That was a lie for many of them. And they cannot agree on what to replace it with. That was not a lie.


The premise of the article is flawed:

No law can succeed when the party in charge of administering it is deliberately trying to make it fail.

Who could have ever predicted that a law passed on a purely party line basis would not be protected and defended by the party that voted against it?

McCardle predicted this, as could any non-delusional person.

Another false premise.

This is not about whether the law is "protected and defended" or even faithfully executed, this about the opposing party deliberately undermining the law even if doing so harms the country in the process.

When was Arlen Specter ever nominated by the Democratic Party or elected to Congress by Democrats?

Just because McConnell declared Arlen Specter a traitor, that does not make him elected by Democrats.

Arlen Specter switched to the Democratic party in April of 2009 and the vote for Obamacare was December of that year. I am pretty sure April comes before December.

Indeed, the Republicans were quite reasonable and sensible in all of this.

The fact is Republicans had nearly a decade to actually agree upon an idea to 'repeal and replace' the system. The idea that it's just casual political business as usual that the current administration will simply sabotage the present system and harm people just because that's 'partisanship' is a travesty.

Imagine if after George Bush's idea to privatize social security failed he decide to just 'have checks get lost' just because he wanted to 'show how bad the current system is'.

Imagine if after George Bush’s idea to privatize social security failed he decide to just change the system wholesale via executive order. Imagine your outrage if Obama reversed that!

Ie, you believe Reagan unconstitutionally paid higher Social Security benefits that were not authorized by the reform bill he signed in 1983 which gave the formula for inflation adjusted benefits, but did not authorize paying higher benefits?

And since 1985, the IRS has been spending tax revenue that was not authorized by adjusting tax tables for inflation thus spending unauthorized money to reduce taxes?

Anyone proposing or even dreaming that a top down health care system for 340 million people is smoking something illegal. It is impossible. It cannot work because by the time some Czar in Washington gets evidence of a problem they have a crisis. Any adjustments require straining it either through Congress or something akin to the VA health administration.

The largest single payer system in Canada serves 13.6 million people. The Federal administration of health care is simply shovelling money out the door with some very broad principles on how it can be spent.

Why are Democrats so parochial? If you want to solve this, look at how things have been solved in places where it works a little. Don't look at failed centrally controlled states that never worked.

So have states as bargaining agents. Or small states can group together to leverage a larger population.

Whoever says "its impossible to have a single payer system with 340m people because 340m is a mighty large number!" is intellectually lazy to the extreme. The IRS and SS administration are efficient and effective in what they do, so you need to explain precisely why insurance must be different.

Are you kidding? The IRS collects taxes and the SS admin writes cheques. They are blunt instruments. If you want a health Care system that is a blunt instrument then you fully deserve what your will get.

Medicare covers everyone over (I think) 66, and seems to function okay. So it's hard to see why Medicare couldn't be expanded to everyone. It would cost a lot of money, and it might not do much for controlling medical inflation, but why do you think that couldn't work?

Please read what I actually said. I'm criticizing the idea that single payer is impossible simply because we have a big population. That's a stupid argument, and we have government agencies that function well with low administrative overhead.

There are many good reasons why single payer might not work, but "large population" is not one of them.

So does that mean you're in favour of Medicaid for all? Medicaid is administered by the states so it fits your requirements.

"Americans are increasingly inclined to see health care as a collective responsibility. Six in 10 Americans now think it’s the federal government’s duty."

They've been brainwashed by the media for years and/or haven't really put any thought into it at all.

Yes, what really makes America great is everyone looking out for themselves and saying to each other "I got mine, screw you!"

RE: media brainwash: I didnt' realize this till I got DVR with slow-mo. After every segment on CNN, Anderson Cooper subliminally messages "You care about your fellow Americans" in dulcet whispers. Damn him!

If you are interested in why legacy media is plummeting in trust, rightly or wrongly, here are a few things to look up.

CNN milwaukee call for peace (CNN deliberately editing out "burn someone else's property down" and calling it a call for peace)

CNN blackmail (CNN, having nothing better to report on, gets huffy at a meme, locate a guy that didn't make it, threaten to dox him if he doesn't apologize)

CNN O'keefe nothingburger (CNN upper level guy confessing on camera the Russia connection is hypothetical)

CNN wikileaks illegal for you (CNN says that you, citizen, cannot legally look at Podesta's emails, only Certifiable Journos can, so trust us and don't look into it for yourself).

There's more, and that is in less than a year.

Stop triggering me with CNN!

It just makes me flip into compassion, all Manchuria-candidate style. Can't...stop...empathizing....bwaaaaaaaaaaa!

"Covfefe". LOL! thanks for riffing with me.

in full compassion-bot mode

Sam, no one' a Sham. We are all miraculous beings of God, or Evolution, or whatever.

You're too hard on yourself. Naps and puppies can help.

Aw, shucks! I needed that. You're an ok guy yourself! Now, uh, what's the codeword to make us angry again? Covfefe?

lol, market capitalism is collectivist crap fool. A scam of scams. Plutocratic dictatorships is what you wants, you should commit suicide.

I have to agree with rage there. Without the rule of law and bourgeois legal structure, "I got mine" doesn't work. It is not natural. Human beings run in packs. You need the law to train and make people docile to accept "private possessions". The Nuclear family is another good collectivist scheme. Nothing about it is natural. It it totally enforced by the bourgeois state. Collectivism as Guenon and Evola said, comes from very interesting places.

Sorta like the ancestry of Ron Paul. His mentor Landon was quite the Jew. Ron has quite the background with the de Rothschild family.

lol, Trump is a half-jew traitor and Obamacare has already succeeded in terms of what it was written to do.

Only the free market collectivists want plutocratic control of health care. It is a Federal Government duty, much like providing a national defense.

Then the Federal Government must have other duties as well. A National Clothing Allocation Service. Federal Toilet Tissue Assurance Administration. Homeland Radon Abatement Agency. National Toothpaste Certification and Dispensation Department. Healthy Pets Veterinary Agency. National Corrective Sunglasses Development Administration.

Don't you dare try to make lefties see how ridiculous they are. If you force them to think anything through, you're just mean.

Chuck if your level of understanding of the problem is so low that you don't see the difference between health insurance provision and "clothing allocation" then please follow an economics 101 class or at the very least look up "adverse selection" on wikipedia. Once you are at least a bit informed, you can come back and try to contribute to the debate.

Where is health insurance listed as a power of the federal government in the Constitution?

"Obamacare has already succeeded in terms of what it was written to do."

Finally a rational comment, if, of course, what it was intended to do was to undermine our healthcare system.

From this day forward, it is Trumpcare.

If this isnt desperate bleating, i dont know what is.

Nope. If you dynamite it you fix it.

That works even better than clumsy breakage.

If my rates go up I certainly won't be so stupid as to blame Obama.

Not doing anything is not dynamiting. Sorry, Obamacare was so badly written that Republicans don't have to do anything for it to self-implode.

Lolz. No one will be able to sell this as nothing, let alone "doing everything we can for voters."

They did something today.

No they did not. The Courts did something a while back. They declared Obama's unConstitutional action unconstitutional.

Trump simply accepted that reality.

Sorry, but your boy is calling this dismantling. You all will need to own that.

It may not be Trump's responsibility in some moral or legal sense to make Obamacare work, but if it collapses and causes a lot of problems (people losing their insurance, insurance companies going out of business) under Trump, he's the guy the voters will hold responsible. Think of it as the pottery barn theory of health care reform.

I don't think executive actions will create branding strong enough to overwrite "Obamacare" in the public's memory.

Meh, I'm a little to the right of Genghis Khan apparently, and I firmly put the guilt of the ACA on the Republicans now. The Democrats have become irrelevant, and the people who claim to want to fix things refuse to upset the status quo. Right or left we should be able to agree, the status is NOT quo.

Well today's reporting is pretty clumsy, trying to square "Obamacare" with executive actions that make it something else entirely.

If not Trumpcare, what?


And the next democratic president can just re-state these provisions that were erased "by the stroke of a pen". Am I wrong? The law will still be on the books. It would still have been on the books even if a re-vamped health care law had passed through reconciliation.

And if you tell me the markets wouldn't allow it, then I'm going to have to tell you the same thing about what Trump did today.

do you think insurers are going to rush in to a business that's likely to change at the change of the presidency?

They'll still need to carry people with pre-existing conditions, right? That will be something the Democratic president will enforce. To do that and not lose money they'll need subsidies/young people forced to sign up/ or something. To get those they'll make another deal with the Democratic president to get back into the markets. It's just what Trump's doing now, but in reverse.

If this doesn't happen, then the democratic congress and president will pass something via reconciliation that will attempt to solve the issue. It's sad that we have this back and fourth, but I see no other solution in the cards. Neither side is willing to back down on this issue.

And if the Republicans maintain control of one of the branches of government this will stand, and we'll have chaos in the markets for the foreseeable future. The Democratic party is not going to roll over on this issue I'm nearly certain.

Sure a Democratic president can reverse this reversal, but i can assure you that Insurers are not going to be hot to join in on such an unstable game.

If the D's can pass something then that changes things quite a bit, but thats the point, if you want your changes to be stable you need something like a consensus that it is worth keeping.

Sure, I agree with you. The hope here is the hope with everything regarding Trump- the nihlists who want to blow up the system will piss off enough people that a consensus can be built following this administration. Fingers crossed we get there. But yeah, there's no agreement on anything at this point.

Trump and Congress could govern in a real populist way, from the polls. There are plenty of things that are majority backed, and waiting for someone to take them up.

The Trumpians and the Republicans both won't though, because they both represent different minorities pretending to be majorities. They fight over that instead. Now with Brannon trying to primary everyone.

All of this will be forgotten in 2020. We'll be voting on whether Korea War II was a great success or not so much.

Unfortunately, more than a small chance this is correct.

Law's been a rococo mess from the get-go and the individual market's been imploding one state after another. I hear from the partisan Democrats here that it's anyone's fault but Obama's and the Democratic congressional caucus.

There's an idea of Megan McArdle, an abstraction. But when you look her in the eye, shake her hand, and look at her bowtied husband she's simply not there.

Yes somehow all the states have been 'imploding' (whatever that means) yet coverage rates have never been higher.

"California led the nation in expanding Medicaid. Having health care coverage, however, is not the same as having access to care. California consistently ranks near the bottom of national spending per Medicaid enrollee, about $5,300 compared to about $10,700 in North Dakota. Medi-Cal [=California Medicaid] payments to providers have not kept up with the cost of providing care. For instance, for a visit to a primary care physician, it’s about $16 – less than the cost of a haircut. As a result, Medi-Cal beneficiaries can’t get care because there aren’t enough providers in the health plan networks."

"California is harming medical care for more than 13 million lower-income residents, more than half of them Latinos, by failing to pay doctors enough to provide proper care, according to a lawsuit filed Wednesday. The lawsuit alleges the state violates Latinos' civil rights because poorly paid health care providers balk at providing treatment. It alleges the low reimbursements often mean that those who rely on Medi-Cal, the state's health care program for the poor, are denied timely and quality medical care. ... One of those suing is 33-year-old Saul Jimenez Perea of Clearlake, who has cerebral palsy and suffers severe seizures that require frequent hospitalizations. It took months for Perea to see several specialists since he is covered by Medi-Cal, according to the lawsuit."

2nd link is dead.

Sorry if the first link is paywalled.

What is the evidence for your claim in, for example, Kentucky?

Not to mention California, New York, Massachusetts, et al.

The States with problems are the States trying to let every person force everyone else to pay because they were once 20 and healthy so they should not pay the health care costs of someone 55 years old, even if they are 35 years past being 20 years old.

What an absurd piece. The statute that outlaws murder, which even Libertarians mostly agree is a good and worthy law, could not withstand being intentionally undermined by those in charge of enforcing it. If we ever ended up in such a situation, your reaction better not be to shrug and say "I guess outlawing murder is unworkable!" Rather you should try to get competent and non-malicious people in charge of enforcement as quickly as possible!

As with murder, the administration of a law like the ACA is an ongoing endeavor.

There is near universal agreement that murder should be illegal, not so much so with Obamacare. The article is not absurd, its totally unremarkable; in order for a law to be durable it needs more support than just the executive's pen.

The complete legislative failure to either repeal it or pass a sensible framework for reform or replacement indicates more than just the executive's pen support. This is a failure not of Obamacare but of leadership or our lack of leadership from the DayCare in Chief's desk.

Well then, Obamacare should be fine. Just marshal up that support you are so proud of and write the subsidies into law.

Yes. It indicates that Republican politicians are comfortable being the same whores for the health insurance industry that Democratic politicians (and the party at large) chose to become when they passed ACA.

The former was well understood when the bill was passed. The latter, particularity the parenthetical, was somewhat surprising, but at this point, it's indisputable.

Doesn't the GOP failure to repeal ACA indicate that the ACA is more politically defensible than many thought? It was easy to convince people that ACA was bad when Republicans could lie about being able to replace it with a system offering better and cheaper insurance to more people. But looking down the barrel of what repeal *actually* means seems to have changed things.

It remains to be seen whether Trump will pay a price at the polls for spiking the healthcare law. But the fact that Republicans in Congress seemed to be too frightened of the political repercussions to actually pass repeal may be an early indicator.

No, it means that the Dems and the GOP are just wings of a single bigger party, the Government party.

Lots of unhinged comments. I wonder how many who are on the verge of rage strokes here are likely to be affected, have any real concept of how many people will be affected, and how many are just "Obamacare Yay Smile Happy Face Goodness" emoting.

It's kind of boring that the closest people can come to supporting Trump these days is an argument along the lines of "isn't it fun to see liberals upset"

I didn't say that or imply it.

Roflmao, I am not a big fan of Trump, but the rage he induces in some outspoken political leftists is a lot of fun.

Watching liberals being upset is never boring.

The longer Trump is in power and the more he causes coronaries in people like you with his Tweets, the more I worship the man.

Yup, starting with you. A big part of Trumps goal is to give China more control of world politics. Check. Give Russia more control of US finance, check. Israel free to commit mass genocide against Muslims.

The dumb lead the dumb. Use thy head. DNA test Donald Trump. If his blood is Ashkenazi on his fathers side, he must resign and be deported from the US. If it is not, he gets to stay as President. My family's old name the Butte's then changed to Bott when part of them moved to Britannia at some point 100's years family that stayed in the Germanic regions met in the 19th century a family called the "Drumpf's" from eastern europe. They were crooked Ashkenazi merchants. This Drumpf interestly sounds like Donald Trump's great grandfathers name, both last AND first name. I got it all in family records that go back to the 19th century from Germany. My, my, my. What things we find.

Get back on your meds, prior.

Finally someone talking some sense here!

People here are routinely grudging about Ms McGargle. Have you all tried to Weinstein her, only to be turned down? Are you all inches shorter than her? If Mr Cowen could write as well as sher this blog would be a better, finer place, bringing more sunshine to the shade of the dismal science.

She is a Good Thing; you should all be ashamed of yourselves for your graceless complaints.

There’s an idea of Megan McArdle, an abstraction. But when you look her in the eye, shake her hand, and look at her bowtied husband she’s simply not there.

For the sake of this one comment, I shall pardon the rest of this article's comments.

McCardle has confidently announced that every negative piece of Obamacare news proves it is doomed since the website was bad.

I've said it before and I'll say it again...Although the ACA had many problems, it's hard for me to believe that a good-willed bipartisan attempt could not have made life much better for many citizens over the last seven years. If that's not incentive enough for politicians to cooperate, then there will continue to be a healthcare mess into the indefinite future.

Perhaps I only saw one side of the story, but it didn't seem like Republicans were interested in changing the status quo back in '09. So no incentive to cooperate if you don't think there's anything to fix.

I wish we could have started the conversation by agreeing that having 20m uninsured Americans was a bad thing that we should try to fix. If the GOP doesn't agree with that statement, at least get them to say so and admit they have no desire in solving a non-issue. But if both sides did agree, then we could have had a real discourse.

Now no one knows what the GOP plans, a direct return to the pre-2009 status quo? It doesn't seem like that. Otherwise they would directly say "things will be great again like they used to." And they had nearly 10 years to figure this out.

"If Obamacare dies now, in this way, the country will be worse off than if it had never passed. ...And the memory of Obamacare staggering onward for years, down a trail of broken promises and underwhelming results, will make voters reluctant to trust any politician who suggests that we embark on another such journey."

Returning us to something a bit worse than the pre-Obamacare status quo and entrenching it for a long while is a pretty good situation for those who reject the whole push for universal, 'gold plan' type coverage.

Your mean Trump and the GOP will stop promising free lunch health care and tell everyone to buy a gun and one bullet and put a bullet in your brain to cure any medical problems?

Fire ten health care workers and create one job selling guns and ammo to boost gdp growth and create jobs?

The second amendment health care plan?

It is the government putting its guns to the heads of some people in order to take their money and use it to pay the medical bills of other people. Why aren't you donating all of your income to pay other people's medical bills, you mean-spirited Scrooge?

"Returning us to something a bit worse than the pre-Obamacare status quo and entrenching it for a long while is a pretty good situation for those who reject the whole push for universal, ‘gold plan’ type coverage."

So do you think that tens of millions of un-insured people is a pretty good situation?

Okay, it's possible to screw up the ACA, and Americans will mostly accept that the basic faults were baked into Obamacare right from the start, so socialized medicine is as evil as Republicans have always claimed so we should get rid of it.

Sheer brilliance. Thank you Republicans. And now you can do the same thing for Medicare and Social Security, right?

One thing that is seldom discussed and remains so terribly baffling is that virtually every developed country has a health care system that is much more effective and costs much less than ours, and yet we in the US still persist in trying to prop up our Byzantine private profit-based insurance scheme. I'm a retired surgeon and if the lay public had any idea how much health care in the US is influenced by what revenue it generates versus what actually works, there would be immediate widespread calls for change.

The problem is the revenue you speak of went in your pocket and that of the insurance companies. Every dollar saved on health care costs is a dollar less of income to someone. Health care jobs are among the best in the country. Those people (AMA, insurers) fight any sensible cost cutting solution.

Doctor's salaries make up 9% of healthcare costs. If you enslave them you buy a whopping three to four years before healthcare inflation eats all the cost savings of enslaving the docs.

The top six insurance companies had a combined profit margin of $6 billion dollars. Let's quintuple that to estimate the profits of the entire sector. That is still less than 1% of healthcare costs. You could confiscate every dime of insurance company profit and you would not even stave off a single year of healthcare inflation.

So what are the big cost burdens? Hospital care. Nursing homes. Clinical services. Administration. The vast bulk of the costs are for things that either keep people alive, are low wage jobs that most people think are too demanding to consider at the pay offered, or are bureaucrats safely ensconced next to the levers of power.

There is no simple magical fairy dust waiting to lower healthcare costs.

"There is no simple magical fairy dust waiting to lower healthcare costs."

Couldn't agree more. We're never going to have super cheap healthcare in this wealthy nation.

There are not wealthy nations with better healthcare systems?

The reason health care expenditures per capita are so high in the US is because medical costs are so high. Medications, hospital stays, tests, procedures, almost everything is more costly here than in other developed countries. And there are very powerful special interests that want to keep it that way. Other developed nations have been successful in keeping costs lower than ours without compromising care (In fact, the care is better But it may be too late for us here in the US to make the necessary reforms, and we will be stuck with an inferior system.

Not this BS again.

When you ask doctors in a Beveridge system of healthcare if they, "report time spent on administrative issues related to insurance or claims is a major problem" it is going to come back that they rarely do shockingly because there is virtually no insurance to bill. Similarly, asking about if you have a way to reach your doctor after hours heavily reflects culture more than healthcare system.

Or somehow it is bad thing that the US is best at talking to below average income patients about diet, but even better still at talking to above average income patients.

You cannot seriously compare the outputs of healthcare systems unless you also compare their inputs.

Just another hack job that is not even internally consistent.

blank bump

I'm a current Emergency Med doc who has worked overseas. Our system has plenty of faults, but we are not particularly less cost effective than anywhere else. My patients here in the US are collectively vastly less healthy than those from overseas in the developed world. Their A1Cs are higher, their BMIs are higher, their pack-year histories are higher, their self-harm rates are higher, and on and on the list goes. This says nothing of the much higher rates of social pathologies like violence (of all types), MVCs (thanks to more mileage driven), or single parenthood (a huge independent risk factor for mortality).

Sick patients cost more to treat. This is why the VA, a single payer system that only provides about one-third of its patients' care, still spends more per-patient than countries with comparable sized populations. In the modern world the biggest risks you can take on health-wise are metabolic syndrome, depression & self-harm, and substance use. These are higher in the states than in any other OECD country.

Another confounder is the cost disease of the US. In the US it is vastly easier to go be software engineer, an investor, or a chemical engineer for very high salaries if you are the sort of person who can hack medical school. This naturally drives up MD wages and similar effects happen throughout the skill ladder. It is easy to have cheap healthcare prices when everyone makes terrible wages; unfortunately I would rather not reduce wages the Alabama average just so our healthcare can reap the benefits of cheap labor. After all, if Sweden joined the US its incomes would be the among the poorest of any state in the country. Wealthy countries have to pay more for labor; healthcare is idiotically labor intensive. If healthcare does not cost more in a wealthy country, you are doing it wrong.

Lastly, good luck finding accurate statistics. In the US getting your MD is likely around a million dollars with eight years of foregone income, undergraduate tuition north of $50,000, medical tuition likely around $200,000, and of course the nice effects of compound interest that stick around throughout residency/fellowship. All of this is recouped in physician salaries. In France, in contrast, you study for six years and, last I heard, eked out a small net positive income for the duration. Obviously, this training is not free, but the costs show up in the education budget and not solely in the healthcare budget. Likewise, the time-cost of wait lists are lost hours of work, increased disability payments, social housing payments and the like. Again none of those show up as healthcare costs, they just come out of other areas. After all what is the best medicine for my frequent flyers in the ED? Housing, counseling, and social aid. Making housing more affordable to the destitute is not cheap, but doing so would drastically lower the medical bills. Of course this would show up on a different budgetary line item.

Even with the medical data is hard to do a direct comparison. Should we compare life expectancy? Not a good idea if your populations are different ages. How about life expectancy at birth? Still troublesome if one country has significantly higher rates of premature birth thanks to increased smoking, drug use, and maternal obesity. How about life expectancy at birth for full term children? Still not a good idea if one country has lower rates of selective abortion heavily culling things like trisomy 21, 18, or 13 from the figures. How about childhood mortality? Not such a good proxy for healthcare when the leading causes of mortality in one is brain cancer and in the other is motor vehicle accidents. How about something simple like vaccination? Well the US is in the top quarter for offering adults vaccination opportunities ... but below average when it comes to accepting them ... and they are all free to patients by law with insurance, insurance they are legally required to have.

So please, let's look at the current world. Americans have worse health metrics to start off, everything is more costly here, and comparisons are terribly non-trivial unless you are being ignorant or deceitful. There is a reason that Vermont, between Luxembourg and Estonia in population, was not able to afford universal healthcare when they tried, and it is not because Vermont is a rabidly conservative state.

Because we refuse to bargian for anything. A single payer system would have enormous economies of scale and could bargain down all sorts of medical costs. Instead we have microscopic insurance plans on a state by state basis that are individually weak.

The insane cost and time investment for becoming a doctor is also part of it. So much healthcare could be distributed by nurse practitioners working at Walmart

It is odd that no one else has found this to be true. It is true that the NHS has been able to bargain down the costs of the doctors and nurses. That is why they depend so much on importing Third World doctors. It is also true that they can bargain down the cost of drugs. But that consequence of the US doing that would be no more new drugs. The huge administrative costs in places like the UK are a serious burden on the budget - but never fear! the solution is always to reduce care. Whatever else you can say about the US, very few people die of thirst because the nurses are too lazy to bring them a glass of water.

I agree the problems could be improved with some union-busting. The AMA is too powerful. But if your solution is to replace doctors with cheaper, poorly trained substitutes, the public may not agree.

Utter rubbish.

The VA has a larger population than The Netherlands; its current patient count is greater than all the people in Israel. The VA actively bargains on formulary, wages, durable goods, and everything else. They also have the luxury of having many of their patients receive outside care and ultimately are responsible for about one-third of their patient's healthcare. On top of all that, they have the heavy weight of government regulation and social pressure to take care of "our veterans" on their side.

The VA pays $6166 for per patient per annum for the one-third or so of total care they provide. Or put another way, the VA pays about twice per capita what Israel pays per capita.

Similar exercises can be performed for TriCare or the large insurers. Take Kaiser. They have 11 million patients on the books, or about the population of Greece or Belgium. Signing up for Kaiser's closest approximation of that sort of care is around $5200 per person per annum; of course this comes with a few hundred more dollars in typical copays and thousands of more risk before you hit the deductible. Belgium pays only around $4500 and Greece around $2000 in on the books costs.

The largest American insurers have always been and will always continue to be larger than most national health insurances in mid-sized countries. You have to go pretty deep into the weeds to find an insurer smaller than Iceland so somehow I do not think size is really the relevant criterion.

In reality, plenty of insurers negotiate on all aspects of care. They sit on numbers of patients and revenues vastly greater than most OECD countries. Yet their profit margins are all but a rounding error in healthcare costs.

Care in the US is expensive because you start with patients with worse health (higher BMI, A1C, etc.), wages in general are higher, and comparable cost & outcome accounting are basically impossible given the differences in everything from education to culture.

McArdle rule #1.

Every destructive thing Trump does is Obama's fault.

Not my president!

So it's clear you haven't actually read much she's written....

Only five or six more generations and we'll be as poor and dysfunctional as Brazil.

Brazil is neither poor normdysfunctional.

Maybe we need to hyphenate.

Trump-Obama care.

But, looking on the bright side, there has been no statistically significant decline in the production of argon in the territory of the United States during the Trump Administration.

I think Trump and other Obamacare haters will be pretty disappointed with the outcome of the removal of the CSRs. It will likely be much less disruptive than they think. Basically, subsidized consumers will purchase the same coverage they've been purchasing via the marketplaces at higher gross prices but the same bet if subsidy process they've been paying, and unsubsidized consumers will purchase plans without the filled in cost sharing off marketplace at a lower gross (and net for them) price. This is actually basically how the pre-ACA Massachusetts exchange worked, and it worked pretty well.

In some ways, deciding to definitely kill the subsidies helps these markets by providing them with certainty.

McArdle is awfully confident that the insurance subsidies are illegal. So far, one district judge agrees with her that when a law says the government "shall pay," it's illegal for the government to pay.

Granted, there are complications, but I don't think her confidence is justified.

I used to read her stuff, and got tired of ideological bias and outright foolishness of much of it.

First the meta-question, Tyler.

Why not pose a question like: What are the economic benefits of 'good intentions'? (For a litmus test, why not ask what are the economic costs of 'military might'?)

"Framing" is something we, well Americans actually, love to accuse 'the so called liberal media' of. Yet here you can recognize that your readership is asked to respond only to the cost of being good. Or of expecting good from others. Or good from their civic leaders. Let me urge you to explore the value of good, goodness and good behaviors. Healthcare is only one market btw, right?

Anyone can willfully blind themselves and their readership to a model of the world. But here is the question: Is there any economic argument that US healthcare must cost more per capita than all other nations on the planet, while refusing to service ~40million people that the AFC act sought to remedy. (btw, is Obamacare a neutral term of art?) I doubt it. But you have economic tools that I lack.

How might you explain why universal healthcare in France, as one example, is more affordable than an exclusionary model that the US is beholden to?

You do make a persuasive argument the America, and its Americans, have grown "complacent".

Is it possible that your own economic framings are also complacent? Is it possible that your complacency has the self congratulatory effect of encouraging Megan to write more on the ideological failures of Obama, when the whole culture of America is depriving its whole, as well as specific communities (blacks, females, self employed come to mind...) from the benefits of 'being healthy'. So did Obama fail, or did his country fail his mantle?

You could also compare the economic benefits of universal healthcare to say, the relative economic benefits of a military budget. By relative I mean the order of magnitude of dollars invested in good, versus (military) might.

Again, "what are the economic beneifits of a completely healthy nation?" Fair question? I think so. If for no other motive than to control for bias.

Go ahead. Shrug off your own complacency and give it a some critical thought. You may find that some of the ways you currently frame an economic argument blunts your ability to reason about a preferable future.


I suspect that the Democrats will learn from this that simpler solutions are better and go with some version of Medicare or -caid for all on the next go-round. I'm somewhat agnostic on that solution, but I think that private insurers are going to eventually be the big losers on this one.

I suppose this makes a good case for limited government. The Supreme Court failed to reign in this over reach. Executive orders, whose legality is in question, were used to throw enough money to cover for mistakes.

A March 2015 Senate Homeland Security hearing revealed that 6.5 million names of people over the age of 113 years old are still on the Social SecurityAdministration rolls - Wikipedia lists about 5 over that age in the U.S.
Obamacare and every other government entitlement program requires a SSA # and it is likely widespread waste, fraud, and abuse along with an inefficient bureaucracy exists in the Congressional follies "gone wild".

I suppose Trump could undo the Obama executive delay on the ACA's "Cadillac" tax if he really wanted to educate the Democratic Party's Middle-class voters as to the real cost associated with the ACA.

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