The Problem with ObamaCare

ObamaCare’s Relentless Creation of Second-Class Citizens (4)

By lambert strether of Corrente.

And we go to Happyville, instead of to Pain City. –Thomas Pynchon, Gravity’s Rainbow

By design, ObamaCare doesn’t treat health care as a right, and does not give all citizens equal access to health insurance, let alone to health care. In three earlier posts, I gave examples of the whimsical and arbitrary distinctions that ObamaCare makes between citizens who should be treated equally; in this post, I’d like to give three more. Two are based on jurisdiction; one is based on class. I’ll start with jurisdiction.

First, let’s talk about how 11.5 million poor people got thrown under the bus because of where they live.

Our famously free press, along with the ObamaCare sales force, keeps saying that ObamaCare provides “universal” coverage. In practice, ObamaCare will cover only 7 million additional people in its first year, and leave 26 million without coverage when and if it’s fully rolled out. Sloppy implementation could account for that, of course — or the sheer fun of throwing people under the bus — but ObamaCare, right now, could neverprovide universal coverage. This propaganda video on flat out lies: “And now everyone will be able to find health insurance at the health insurance marketplace.” No, not “everyone,” and the reason is Medicaid:

When Americans begin shopping for benefits on the law’s health insurance exchanges on Oct. 1, the people who would qualify for Medicaid but live in the 20-plus states where Republican governors or state legislators won’t approve the expansion will see a note explaining that federal law allows them to get coverage that their states’ leaders won’t provide them, said Jeanne Lambrew, deputy assistant to the president for health policy.

(One can only wonder whether the note give the contact information for the state’s Democratic Party.)

Why can’t they get coverage?

Obamacare set aside billions of dollars for states to expand their Medicaid programs. Twenty-four of them, most led by Republican governors, have opted out since the Supreme Court ruled a year ago that states could choose not to participate in the expansion. That’s left their low-wage workers in a bind: They make too much to qualify for Medicaid in its present form, but too little to afford a plan their employer might offer. And they don’t earn enough to qualify for subsidies available to help the uninsured buy plans on the state-run Obamacare marketplaces opening in October. These subsidies are available to people with modest incomes—$24,000 to $94,000 for a family of four. Democrats in Congress who wrote the law figured anyone making less would get coverage through the Medicaid expansion.

How many are there? Only a few million:

As it stands now, an estimated 11.5 million uninsured, non-elderly, poor adults live in states that have opted out, according to research from the Urban Institute.  What happens to impoverished citizens in states that don’t expand? The most likely answer is that they’ll slip through the cracks and remain without health insurance.

How did this happen? Brad DeLong:

Back in 2009, President Barack Obama could have proposed a program as comprehensive as the one initiated by Bismarck [who proposed universal coverage as part of a successful plan to c-opt the Socilalists]. Such a program could have allowed, encouraged, and made it affordable for uninsured Americans to obtain health insurance similar to what members of Congress have; or it simply could have expanded the existing Medicare system for those over 65 to cover all Americans.

Instead, Obama put his weight behind the complicated ACA. The reason, as it was explained to me back in 2009, was that the core of the ACA was identical to the plan that former Massachusetts Governor Mitt Romney had proposed and signed into law in that state in 2006: “ObamaCare” would be “RomneyCare” with a new coat of paint. With Romney the Republican Party’s presumptive nominee for the 2012 presidential election, few Republicans would be able to vote against what was their candidate’s signature legislative initiative as governor. Thus, the US Congress, it was supposed, would enact the ACA with healthy and bipartisan majorities, and Obama would demonstrate that he could transcend Washington’s partisan gridlock.

Of course, the explanation proffered by DeLong’s interlocutor is exculpatory, self-serving nonsense; a classic exercise in Democratic blame-shifting. (Had the White House been acting in good faith, they would not have censored single payer advocates, but allowed them to drag the Overton window left.) The Republicans were and are the party that impeached Bill Clinton over a **** ***! There was only one way to deal with them — well,besides morphing into them — and that was force majeure. And in 2009, the Democrats had the House, the Senate, the Presidency, while Obama — the greatest orator of his time, remember? — had a mandate for “hope and change,” and the Republicans under Bush the Lesser had been completely discredited in the eyes of the public; the 2008 election was a virtual referendum on them. If Obama, and the Democrats, had truly wanted a universal plan that guaranteed health care for all Americas as a right, they had the political power to pass it, and by a majority vote (either through reconciliation or by abolishing the filibuster). There’s no point blaming the Republicans, whether in Congress or in the state houses, for unforced strategic errors by Democrats (if errors they were indeed, and notsimply corruptionin 2008 Obama — unlike She Who Cannot Be Named — neveradvocated for a universal plan in the first place).

The bottom line here is that if Obama and the Democrats had advocated for and passed a single payer Medicare for All plan in 2009 — which they had the power to do — 11.5 million poor people would now be going to Happyville: They would be first class citizens with access to care today. Instead, the Democrats sent them to Pain City in the Second Class car.

Next, let’s talk about geography. To be fair, there are some forms of discrimination that ObamaCare forbids: Gender, prior conditions, and so forth. But there’s one major form of discrimination that ObamaCare preserves and legitimizes: Geographical discrimination. Here are two examples.


[Julia Lambert, president of Wakely Consulting Group] said the monthly average premiums are “all over the board depending on who you are and what plan you choose.”  Geography … makes a difference. Litchfield County has the lowest average premiums in the small group market and Hartford County has the lowest average premium in the individual market. Fairfield County has the highest average premiums in the individual market.


For the same health coverage from the same insurer, a 40-year-old Sacramentan will pay $78 more per month than a Los Angeles County resident through the state’s new insurance exchange.

In rural Mono County, the disparity will be even larger: $150 per month, nearly 60 percent higher than for identical benefits and co-pays offered in Los Angeles County.

The premiums provide relatively basic coverage from Anthem Blue Cross, but similar regional differences exist in plans proposed by other insurers. The numbers reflect new rate-setting standards: How sick you are no longer matters, but where you live does.

“This is a huge change from the current marketplace, where people are rated individually based on their health status,” said Anthony Wright, director of Health Access California, a nonprofit advocacy group.

How on earth can this be justified? Why should a first class citizen who lives in Los Angeles County go to Happyville with a lower premium, and a second class citizen in Mono County go to Pain City with a premium that’s 60% higher? I suppose the answer will be: Because that’s necessary for the actuarial soundness of the program. But that logic applies to a profit making entity like a health insurance company; it doesn’t apply to a government agency working for public purpose (unless that agency has been cognitively captured by private industry). I mean, we don’t pro-rate Social Security benefits for life expectancy by Zip Code or Standard Metropolitan Statistical Areas, do we? So if we don’t discriminate by geography for Social Security, why should we do it for ObamaCare?

Third — and I have to admit this is a relatively minor, symbolic gripe — this headline really frosts me: Obamacare exchange navigators expected to earn $20-$48 per hour. That’s — let’s be generous — from $10-$38 more than many an adjunct professor makes, teaching our children organic chemistry or calculus or Mandarin or (heaven forfend) how to write a coherent essay with a topic sentence and logical flow.

So I guess that tells you how complicated ObamaCare really is, doesn’t it? Walking somebody through it pays better than teaching a college-level course.

The God(ess)(e)(s) Of Your Choice, If Any, know that people need jobs, but I’m envisioning a classified ad that looks like this:

Good jobs in the rental extraction field!Contact:

Of course, under single payer Medicare for All, there could be jobs delivering actual health care, instead of meta-jobs figuring out how to purchase insurance that may, or may not, deliver care at some future date. I mean, how come we’re paying navigators more than we’re paying home health workers who take care of our elders and who, in Texas, will be too poor to be subsidized, yet won’t be able to get Medicaid?

The bottom line in these United States today is that if you get near enough to the stream of rents to skim something off, you go to Happyville, first class. Otherwise, you go to Pain City in coach. Single payer Medicare for All would eliminate those rental streams, which is why the political class won’t put it on the table.

NOTE * The national minimum wage is $7.25, and many adjuncts make less.

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