Back to article

Medicine or poison?

Amending Obamacare could break parts of the health-insurance market

It is far from clear that the Republican plan will work

See article

Readers' comments

Reader comments are listed below. Comments are currently closed and new comments are no longer being accepted.



Just like with Obamacare congress is focused on the wrong problem. WHO pays instead of bringing down the total cost of the system. We need to bring competition to the healthcare system and increase supply faster than demand. That is the ONLY way to bring down costs and make healtcare affordable for the nation.

First, everyone should have to pay the same rate, insurers, government and private indivduals. That rate should be posted, for everyone to see to encourge competition.

Second, if you want to lower costs, you need to increase supply faster than demand (the opposite of what these expansions to insurance do). That will allow competition to drive these costs down. Remember insurance is NOT healthcare. We need to get rid of all the burueacratic hurdles that are stopping more care. (such as the doctor cap).

Finally, if you are getting government assistance, you should be doing everything you can do keep the costs down. IE, put down the donuts, and the TV remote and go down for a walk (or workout). Their should be a requirement to be fit medical condition permitting.

I would also add we need to stop heroic end of life care on the taxpayer dime.

Kroneborge in reply to Some_like_it_False

"we need single payer."

Single payer always and everywhere rations care to keep costs down. Why do we want some government bureaucrat deciding what care we get again? Or maybe making other decisions about how you should live your life to keep costs down?

After all, if I'm paying for your healthcare, then I should get a say in making sure you stay health right? Better lose those pounds


Fuck all this - we need single payer. All Republicans want to do is refashion how the health care industry can gouge consumers. This industry should not be based on profit, but rather saving lives. Instead, US citizens have a choice - get gouged and possibly face financial ruin - or be healthy and live.
And the doctor and CEO get to buy another yacht or island.
Republicans are nothing but enablers for the rich and greedy, always have been. Democrats, on this point, aren't much better. But these Republicans care even less about Americans, only focused on their power and favors they dole out to their commercial allies.
IMMORAL - may these devils get wiped out in the mid-terms and may they go to hell - right where they belong.


Well, here we go again. The Republicans wish to essentially return to a version of what we had before ACA, which is that some people get healthcare and the rest don't until they show-up at the emergency room. And then are bankrupted by the costs. What a deplorable situation. Rather than design a system which provides care for Americans, the Republicans wish to continue to enrich the drug, doctor, and hospital industries and dispose of the bottom two or three quintiles of Americans. If only those quintiles understood last November what they were electing and how it would destroy their healthcare.

Focusing on the insurance aspect of healthcare and not the cost side is doomed to failure. The "healthcare" industry owns too many congressmen and senators and the bozo in the Whitehouse is disconnected. Costs have to be controlled in any insurance model. The "conservative" right-wing is depending on everyone missing this relationship. In the next election the Democrats should have a field-day attracting the bottom quintiles back to their side. That is, if they actually wake-up.

One last comment:

If a poor person goes to the emergency room, they get care like anyone else. If they are on medicaid they get care at the emergency room and/or a doctor's office which takes medicare patients. So it makes sense that one would see little or little difference in outcomes between poor with/without medicate coverage. All get care through the emergency room and the hospital staff for serious illness. But medicaid reimburses the hospital a bit, and for those not on medicaid, the hospital makes-up the costs by charging everyone else a higher rate. So if your argument is to continue to make everyone else "contribute" through the hospital's billing system, then say so. But saying that Medicaid makes no difference is a bit deceptive.

Best regards.


Curious in that on average, insurance premiums have gone up some 20% over the last year, yet as a surgeon, my fees have gone down approximately 5% over the same time, where has the money gone?
The number of smart, otherwise well informed individuals who have no idea what their policy covers or doesn't cover, is shocking. Even I, who deal with these issues daily, cannot reliably tell people what the "cost" of a procedure or test is, but I do know that that cost is dramatically, usually well over 50% less if paid in cash or without insurance.
Several freestanding surgery centers and imaging center have appeared exactly to fill that need. In those cases,, patients are given an upfront verifiable cost, and can elect to have it done or not, but at least know what the cost is. I suspect that you will see people justifiably questioning why relatively simple and non-emergent services such as labwork, elective imaging and elective surgeries, are not done with an actual, quoteable, published price given to them beforehand. We buy goods by comparing prices, service, convenience, etc, why should elective health services be any different. Emergency services are an exception, but constitute a very small part of health care expenditures.
insurance companies are not villians by nature, but of all of us have allowed the system to become so complex that even simple things need ours work of work to understand them, and we therefore pay insurance companies to do this work for us. If we just asked, how much for a hernia repair or a cholesterol level?, and got a price for it, we could let insurance companies sort out the complex things like inpatient stays, rehab, nursing homes, etc. which is where complex understanding is needed. In short, health care in the US is about the furthest thing from a free market that exists, just allow the simple transactions to remain simple.


The GOP hates the Affordable Care Act (ACA or "Obamacare") for the following principal reasons:

1. It imposes extensive regulation revising the private healthcare insurance market to eliminate abusive -- but very profitable -- insurer practices.

2. It creates state and federal healthcare insurance exchanges which allow private individuals to purchase insurance directly, thereby causing insurers to COMPETE with one another, again, limiting their profitability.

3. It greatly expands the Medicaid program -- something which the GOP are ideologically opposed to as a government giveaway to the undeserving reprobate poor.

4. It imposes on every American the social duty to assure that he/she is covered by some form of healthcare insurance (whether Federal or State, whether employer-provided or individually obtained), and enforces this duty by the imposition of a fine through the federal tax system.

The GOP is opposed to these things first and foremost because they wish to greatly favor the profits of their friends in the health services sector, namely, pharmaceutical companies, hospital and nursing home companies, doctors and medical materiel supply companies. Anything which might limit the profits of these companies is something against which the GOP will agitate: All notwithstanding the moral implications of American health services companies profiting from the sickness of their charges.

The GOP is further opposed to these things because of their ideological objection to the intervention of powerful government authority in any aspect of American life: They maintain the FANTASY that the Private Market can always do everything better than anything done in the Public Sector. They do not see any purpose in having Government, as a whole, let alone allowing Government to get directly involved in the provision of any services. And they desperately wish to avoid accepting health services as being a public right, let alone a public utility or service, a "Public Good", to be provided at the Government's expense and without profit, let alone BY the Government, directly.

Yet, the reality of health services in America, today, is that more than 63% of all healthcare is provided by Government Insurance, mainly Medicare, Medicaid, the Veterans Administration, and the CHIP program. Only 37% of all healthcare is provided through private insurance. If the GOP wished to avoid having the Public Sector become the 800-pound gorilla in the room, that ship has already sailed long ago !!

Further, the Medicare and Medicaid systems DO provide over 50% of all healthcare services in the country and in roughly equal amounts. And they provide these services quite well and for as little as a 5% additional administrative cost. (The government doesn't "profit" from this added cost.) This compares to the 25% - 30% gross profit margins typically seen at every level in the private healthcare markets! Simply said, healthcare funded by the Public Sector is fair more efficiently delivered than ANY privately provided healthcare; and this fact has long been known and deserves to be heavily emphasized.

Further, far from seeing healthcare costs spiral out of control, as was long predicted by the GOP before Obamacare was rolled out, the advent of Obamacare has dramatically SLOWED the rise of healthcare costs. What has risen, for sure, is the direct cost to consumers, who now must purchase healthcare insurance coverage where they often took a "free ride", previously. And it is in fact the rise in the direct cost to consumers which has helped restrain the overall acceleration of healthcare cost inflation. So, too, the expanded coverage, leaving now only some 8 % of Americans uncovered, having brought more than 20 MN lives under insurance coverage, has served to limit healthcare cost inflation and precisely because these Americans no longer present themselves aimlessly on the hospital emergency room's doorstep for what amounts to routine care: The expanded Medicaid and Obamacare coverage of routine services has led to a $1,000 per person per year savings for everyone !!

Each of these benefits of Obamacare is directly the result of those very four things that the GOP have long railed against. They cannot and shall not repeal and eliminate these provisions. If they try, they shall fail miserably, and the American Public will hand them their asses for it in 2018.

teacup775 in reply to Kenneth711

So basically you subscribe to gambling as good decision making. Interesting.

I'll agree the penalty was too small but to say having people pay 30% more for a year when they start needing insurance may very well keep them permanently out.

The point of having coverage is to fund insurance and with coverage provide prevention. The GOP bill simply encourages the young and healthy to make counter productive choices.

The ACA mandate at least didn't brutalize people when they bought coverage.

Melissia in reply to PamSkeen

Actually, the Affordable Care Act does not force insurers to cover transitioning treatments. It merely bans insurers from categorically excluding all transitioning treatments from overage.

Meaning, the insurer has to offer some kind of plan that includes coverage for transitioning treatments, but not all plans have to offer coverage. Thus for the most part, transpeople wanting to undergo transitioning treatments and wanting to be covered for it by insurance need to purchase more expensive plans.

JKPbody64 in reply to L-gharef

"The easiest plan: Scrap Obama-Care. Don't replace it. The free market will take care of the rest."

Prior to the ACA and based on the proposals described above there is no free market, or anything remotely like it, in the American health care industry. One of the key tenets of a free market is informed choice based on perfect information. It is impossible to tell how much any visit or procedure will cost, it is extremely difficult to get accurate quantitative information on the quality of care. In this environment the notion of competition is meaningless. If a proper functioning free market did exist then maybe you'd be right, although I would point out in the cases you mentioned the government is involved in every one of those markets.

In truth organizations like the AMA act like a medieval guild and are opposed the information requirements of a free market.

MySetDancer in reply to Kenneth711

"The block grants will force the states to spend the money wisely or else pick up the extra themselves."

I am not sure I follow you on this. If the state's electorate don't demand that the money be spent wisely under ACA, what makes anyone think that the same voters and state government will do so under the Republican's plan? Aren't they the same people? What compels them to do a good job? According to your assertion, no one has been and there is nothing in your assertion to suggest this will change. I don't think block-grants do much except allow the Republicans to reduce the grant amounts over time in order to strangle the program. State which currently mismanage medicaid will certainly continue to do so. Trump is certainly not going to allow additional red-tape and requirements, so the states may be free to do whatever they like, including continuing to squander federal money.
If the complaint is that "bureaucratic red tape costs and low reimbursement rates" remember that Congress has the ability to immediately correct both. They choose not to. I think we both know why . . .
Best regards.

Your notion that modern healthcare should be financed by only 2.5% of GDP is, itself, ludicrous. Even Nigeria, which spends virtually nothing on healthcare and has an average life expectancy for children born today of only 45 years, spends at least 2.5% of GDP on healthcare !

Further, the US today spends about 18% of GDP on healthcare, not only 12.5%. Here, you're thinking rather of Germany, not even of Canada (which spends slightly more).

The difference between the US and the average OECD nation in the percentage of GDP spent on healthcare rests largely on the excess profits made by health services organizations, here, at every level: This amounts to some 300 BN USD in the privately financed healthcare sector, alone. Further, doctors, dentists and pharmacists are the principal drivers of cost in the US and these are vastly overpaid in comparison with world standards: Together, they account for about 40% of the cost in the healthcare dollar. If their wages were brought into line with OECD standards, another 735 BN USD per year could be saved. All told, some 1.035 TN USD could be saved from just these two sources, alone: Eliminating private healthcare insurance, and placing all medical personnel on the public payroll!

That would reduce the current national tab for health services fro 3.24 TN USD annually to only 2.2 TN, a savings of about 39% in the overall cost, thereby bringing the total down to about 11% GDP in line with Germany.

Makes you wonder seriously why the American People continue to wish to enrich their doctors and their pharmacy companies, rather than fatten their own pocketbooks !!

PamSkeen in reply to MrJefferson

Curious in that on average, insurance premiums have gone up some 20% over the last year, yet as a surgeon, my fees have gone down approximately 5% over the same time, where has the money gone?

Obamacare demands that "sex changes" be covered....that accounts for part of the money.


Just some basic facts:
a) Obamacare will ruin the USA or all the health market.
b) The ACA was motivated by a genuine concern surrounding the problem of dealing with preexisting conditions, even though most of those problems were caused by previous regulations.
c) Obamacare is the worse ever invented law in the planet related health/welfare. That is wrap in few good intentions does not justify this aberration.
d) This fall we saw the cancelation of individual insurance policies. This is a particular tragedy. Here are people who did the right thing: they bought insurance when they were young and healthy, so that they wouldn’t have to do so later when they got sick. You cannot think of a better nudge to get them to leave the insurance system than to just kick them out.
e) The individual mandate, for instance, will surely fall apart as the first few chapters unfold this spring. Given the alternative between $1,000 in tax penalties or $10,000 for health insurance, the choice is clear, particularly if you can always get the health insurance later when you’re sick.
f) The ACA was enacted in response to genuine problems.

In short, only deregulation can unleash competition. And only disruptive competition, where new businesses drive out old ones, will bring efficiency, lower costs, and innovation. Health insurance should be individual. It should be portable across jobs, states, and providers. It should be lifelong and guaranteed-renewable, meaning you have the right to continue with no unexpected increase in premiums if you get sick. Insurance should protect wealth against large, unforeseen, necessary expenses, rather than act as a wildly inefficient payment plan for routine expenses. Obamacare does not do ANYTHING of this less hope that the new one will be better but no chance due to the ideological blind democracts


Anyone who thinks health insurance companies will compete on price for the uninsured is delusional. Health insurance companies don't take risks and don't really compete anymore, except for big company contracts with lots of healthy employees. Unlike property and casualty companies, who take real risk and endure hard and soft markets, health insurance companies make nice growing profits with minimal investment year after year. They are like cable TV companies - quasi-monopolies, happy to sell at high prices their profitable services, and not really interested in the lower end of the market. Here in America, we are buried in ads for property and casualty insurance, yet there is never an ad, anywhere on TV for health insurance. Why bother advertising if you don't have to?

Kenneth711 in reply to 3pvDDE48mB

Of course it is obstructionism but why did the Republicans obstruct? Obama got the AMA and the insurance industry to support Obamacare. They are the two major players in the medical industrial complex in the USA. Their disapproval in the past aborted Hillarycare back when Bill was president. If the GOP is such a toady to Big Business, the Republicans should have let Obamacare pass.

One major reason was Romneycare's failure. Romneycare was started with grant money from the federal government as it was too expensive for the state to do on its own. That grant money was scheduled to end and the state was looking at massive deficits as a result. Romneycare was headed for a shutdown unless the federal government continued to bail it out or pass Obamacare as a replacement. The liberal news media made a big deal of the success of Romneycare but ignored the financial projections that it was heading for a major financial crisis. This meant that Obamacare was also going to go over the same cliff in a few years. Except there would be no uber federal government to bail out Obamacare. The bailout would come in the form of rapidly rising premiums which has already started.

So beyond politics, there was a pragmatic reason for obstructing Obamacare. It had been tried as Romneycare and Romneycare was actually about to go bankrupt. It just had not yet happen when Obamacare was written but the financial projects all were quite definitive that it would shortly go bankrupt.
A web search on "romneycare financial crisis" will find several articles on the failure of Romneycare which is remarkably similar to the problems of Obamacare now.

3pvDDE48mB in reply to Kenneth711

Surprised you're debating procedure vs. the core of the argument around health care affordability ...
We largely agree on the facts there, you're just interpreting it differently. Republican threatening filibuster was the reason for the lack of review as you say. When not a single Republican in the House or Senate votes for the bill, and the bill is based on a Heritage Foundation plan, is similar to one passed by Romney in Massachusetts, how can you look it any other way that saying it's obstructionism?
The ACA bill was extremely drawn out. Obama spent months trying to court Republicans, but the word from the top was, you give an inch and we'll primary you. He had more than 7 months from inauguration if he wanted to ram it through like the GOP is trying to do with their amendment without CBO review.

Kenneth711 in reply to MySetDancer

One major feature of the German and French health care system is the government regulates cost in some manner. In Germany, the insurance companies must sell their basic policy at cost. The American health care system is dominated by institutions such as the AMA who do NOT want any form of price control They also prevent one of the basic features of a free market from being used by their members. When you buy a car, a house, etc. there is a public listing of the price. When you go to a doctor, there is NO public listing of the price for anything. If you ask, you are told "It all depends on whether there are any complications." even if the odds of a complication is near zero. In actual practice the price the doctor will eventually bill will vary depending on whether you are paying or an insurance company is paying. If an insurance company is paying the price will still vary depending on the deal the insurance company cut with the doctor.

The bottom line is the USA medical market is supposed to be a free market but it is really a dark market. The lack of transparency allows doctors, hospitals and drug companies to charge different prices for the same procedures but no one knows this. California now has a law that requires hospitals to publicly post their prices. Reporters found a 10 to 1 variation in prices and NO correlation between price and quality. Some of the best ranked hospitals has the lowest prices.

As long as the government pretends that medical prices are set by a free market when it is really set by a dark market, medical costs will continue to be sky high in the USA. This is a separate and independent problem from health insurance so Obamacare did nothing to fix it nor will the AHCA.

right wing social democrat

It is ludicrous for a modern superpower like the United States to spend perhaps 12.5% of its GDP on healthcare ...

I'd claim a basic barefoot doctor level regime of general practice first aid and drug stores should only use 2.5% of GDP ... Though the surgeons and their golf clubs would miss out. With the plaintiff lawyers and insurance industry papershufflers at work doing nothing levying their keep too.

Million dollar transplants on old people where young roadkill are exploited providing hearts to people whilst the old person's relatives fight over their inheritances, that sort of against public policy medicine out of control pursuing profits for wealthy health professionals, that sort of health care industry brings the Hippocratic Oath into disrepute.

Imagine what everyone could do if their taxes were reduced by 10%. What would people choose to spend it on? Health insurance?