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Medicine or poison?

Amending Obamacare could break parts of the health-insurance market

It is far from clear that the Republican plan will work

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I really don't think if there is any difference with obamacare and AHCA'S, becuase even during the late president not all american can buy their own Health Insurance, and of all the changes that happening right now, we the poor people always affected. I think the government needs to find a good solution that help us instead of squeezing us. For me, I invested to buy an insurance at JS Downey Insurance Services for my family and me becuase I know this will help me especially I am starting to feel those aches and pain, but the thing is many people need this not just me. So, I just hope that they will think a better system that can cater everyone.


Thanks for the nice piece and helpful graphic. Amazingly, the line "[a]mazingly, several studies have found that Medicaid does not improve the health of those enrolled in it" was suggestively slipped in without citation or further explanation. Seems like a topic that warrants its own article at the very least. I believe the studies in question narrowly defined "improved health," and may not have addressed other important benefits associated with having some kind of health insurance. But it's hard to say absent links / references.


With Trump care you get a gun if you're ill. And if you don't know what to do with it, then you're not in enough pain.


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?


The article states that for individual policies sold through the exchanges that subsidies are pegged to the cost of insurance which is not exactly accurate. Subsidies are based on the 2nd lowest priced silver plan offered in a county and, having looked at some of these low cost silver plans available on the exchanges, these low cost plans are really terrible. I live in Palm Beach County, FL and it all of the lower cost plans have very narrow provider networks. One of the low cost silver plans here has 1 in-network rheumatologist who is a primary care doctor for a population of about 5 million and no major hospital that is in network. The narrow networks forces people to out of network services which are not covered by the insurer at all. Even on my $750/month Florida Blue plan (I'm 63) I pay out of pocket for 3 of my 4 doctors who aren't in network and both major hospitals within 5 miles of me are out of network. To get a plan with the same coverage (deductibles, co-pays, etc) but a wider provider network would cost me $1,250/month.

I think that President Obama tried to do too much with the ACA. In addition to expanding coverage in terms of the number of people covered he expanded what is covered. My policy covers a lot of things that I don't need & will never use (maternity care, pediatric vision & dental, psychiatric care, gender reassignment as of 1/1/17, etc.) which really increases the cost. I know that some people need these services and my paying for these services makes it cheaper for the people who need the services but essentially I'm being taxed to support someone else and perhaps these additional coverages could have been subsidized by the government directly rather than as a hidden tax to health care consumers. I'm surprised that the Republican proposal didn't cut these immediately.

Another smaller beef has to do with the fact that low income resident alien benefits in states that didn't expand medicaid are much more generous than for citizens. I have a friend who was in the US legally with a green card and I talked her into becoming a US citizen in 2010. US citizens are only eligible for a subsidy if they earn above 130% of the federal poverty level while resident aliens are eligible for subsidies at any income level. As a resident alien she would have had a subsidy but as a citizen she isn't eligible for the premium subsidy.


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.

Unqualified Critic in reply to Kroneborge

I agree about Congress focusing on the wrong thing, and encouraging healthier life styles. Focusing too much on insurance, which is a psuedo-symptom (in that high insurance costs are another symptom of local health care defacto monopolies, whereas the Affordable Care Act regulated insurance companies abilities to 'weed-out' unhealthy people), is also going after the symptom. How do or can you get Americans to shop around for health care?

Americans can't even get a straight price from their local hospitals, because the hospital won't even talk to you unless you have a middle man insurance company representing you. Also, the rest of Americans making a decent income can't even get reasonably priced insurance without an additional middle man employer using the entire workforce as collective bargaining. As you can see, Americans are thoroughly and systematically removed from bringing any semblance of the real market place rules to bear against insurance and health care providers. A final point reinforcing the sense of local hospital monopolies is that when it's an emergency choice doesn't exist.

I'm pro market place, and I truly cringe at the notion of a national health care system; but I sincerely have trouble seeing how free-capitalism at this point in time is equiped to solve this.


You suggested that the choice was between medicine or poison. May I suggest that the current proposal is not poison but snake oil. It will not kill off everybody, but it sure isn't what anybody but the hucksters thought they were buying into by voting for Trumpcare.


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.

Countries like France and Germany have managed to create a public/private partnership which results in better outcomes than the U.S. AND costs about half of what the U.S. spends in GDP per capita. If they can do it, then the U.S. can. But you are correct in that the healthcare industry owns both the Republican and Democratic parties at the national level. The Democrats has a chance to change the system but opted to go half-way, preserving their campaign contributions. The Republicans are much, much worse.
I predict that Trump will be gone in 4 years, so we only have to postpone the radical right-wing Republicans until the next election cycle. Hopefully in two years we will remove the radical Republicans from office and install moderates from both parties and finally get a chance to pass better legislation. I think there are lots of older Republicans which rely on ACA and will punish the Republicans at the ballot box. I certainly will.

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

Berational in reply to Kroneborge

1) Costs are the problem with US healthcare and a free market system has failed to address this problem. (For well known economic reasons) No matter how much of an idealist you are, the empirical results are in and every country in the world has seen the writing on the wall. Let go the ideology and see the reality of the situation. Control the costs or go bankrupt.

2)Even with triage, single payer systems regularly outperform the american system when looking at the health of citizens and the the economic drags that come with a free market approach (like bankruptcies, and lack of job mobility due to illness)

The problem here is that conservatives are blindly sticking with an approach that is a proven failure rather than accepting an approach that is a proven success, for purely ideological reasons. Whatever happened to conservatives being pragmatic and letting the liberals embrace pie in the sky dogma? Conservatives are now the ideologues incapable of seeing reality even as it kicks them in the ass.


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.


The money given the states to expand Medicaid under Obamacare is classic pork barrel politics. The states got lots of extra money without any need to spend it wisely, only to spend it all. That got the support of many states. How wisely was that money spent? As the article states "Amazingly, several studies have found that Medicaid does not improve the health of those enrolled in it." One reason is many doctors no longer treat Medicaid patients as it is too costly to them to treat them due to bureaucratic red tape costs and low reimbursement rates despite all the money the states got. The block grants will force the states to spend the money wisely or else pick up the extra themselves.

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.

Kenneth711 in reply to MySetDancer

"what makes anyone think that the same voters and state government will do so under the Republican's plan?"

It is very simple. The POTUS is now Trump and not Obama. The states knew they could count on Obama to always give them more money to insure that his signature domestic legislation will never fail. OTOH the AHCA is not Trumpcare no matter how much the Democrats what to stick that label on it. Trump can walk away from the states who do not spend wisely. If anything the AHCA is Ryancare.

3pvDDE48mB in reply to Kenneth711


If the elected members of Congress don't feel like their constituencies care about Medicaid why would they care about it's outcomes?

Vox found through some interviews with Kentucky Trump voters who liked Obamacare that a motivator for their Trump vote was resentment that Medicaid recipients were getting better treatment for much cheaper than their ACA market plans.

Could it be, that in places like this that it might even be popular for politicians to gut Medicaid and divert funds elsewhere?

Kenneth711 in reply to 3pvDDE48mB

"Medicaid recipients were getting better treatment for much cheaper than their ACA market plans."

This is not surprising. Medicaid was an existing entitlement whose financing and benefits were well established. All Obamacare did was lower the income requirements to get it. However Obamacare insurance was a whole new ball game where the financing was To Be Determined. The big problem was how to subsidize those too rich to get Medicaid but too poor to pay the market rate that Obamacare insurance would be charging. In addition Obamacare had many mandates that drove up the market rate by requiring coverage that many people did not need nor use. An example was mandatory birth control coverage. It did not matter that you were a man and there was no birth control for men. It did not matter that you were a menopausal woman who did not need birth control. You got the coverage and it was part of your premiums.

The result was many people had no choice but market plans that were more expensive than Medicaid even with the subsidies. Many of the problems of Obamacare was because it was passed without any review. So these problems where never found out until AFTER Obamacare became law and people could finally read the law and saw what was in it.

3pvDDE48mB in reply to Kenneth711

Republicans flat out blocked anything Obamacare related. You can't have a review if they refuse to flat out consider the proposal. No major legislation is perfect when first implemented but because they opposed any and all changes that weren't repeal, none of those could be fixed. Republicans even opposed extending the mandate start date. They were so intent on killing it by any means possible, they opposed delaying a policy they disliked.
Health insurance works on the basis of spreading the cost / risk across a broad pool of healthy and sick, high and low users of services. It's not fee for services you need specifically. That's health care without insurance. Insurance is by definition paying to spread the risk of needing a treatment until you might need it. That includes services that you may never need.
Medicaid is close to what every other developed country has but unlike in the US you don't have to be poor. Other countries (like here in Australia) have the government significantly push health product & service cost down by being a majority buyer. In the US, the health insurance runs wild with prices because of the absence of a strong near-monopsony buyer. US Medicare is actually pretty close to this model because the government can negotiate on prices. If it was extended to everyone, the costs of healthcare would plummet, but the industry and their lobbyists would fight tooth and nail before that happened.
Here's the cost of epipens here in Australia:
Most pay $38 for a pair (about $30 USD), low income people pay $0.

Kenneth711 in reply to 3pvDDE48mB

"Republicans flat out blocked anything Obamacare related. You can't have a review if they refuse to flat out consider the proposal."

Totally wrong. According to PBS Frontline, Obamacare was passed without review because Obama feared a filibuster that would prevent it from passing. The Senate had already passed a version of Obamacare but the House had its own version. The NORMAL process would be a reconciliation of the two versions which would be voted on by both houses. However that would have allowed the GOP to filibuster the reconciled bill because a special election had just given the GOP an additional seat in the Senate. As a result the Democrats would not be able to shut down any filibuster as they had on the original bill. So Obama decided to have the House pass the Senate version "as is" without any review or alteration. That was when Nancy Pelosi made her famous statement that the House members could not read the bill until after they had passed it.

So the fault is all on Obama. He rushed the process to avoid a possible filibuster because the Democrats MAY lose a Senate seat in a special election. When the Democrats actually lost that election, he punted by getting the Senate version passed with NO review. The result was a very bad bill which allowed the Republicans to advocate repealing it.

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 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.


It seems middle-class Americans are much more hostile than Europeans to providing subsidies for the less wealthy, even to children and those unquestionably innocent of 'scrounging': why?

Kenneth711 in reply to non-juror

Both Obamacare and the AHCA provide subsidies. They only differ in the mechanism used to provide that subsidy. Both use tax credits. Obamacare uses income as the prime test of how much of a subsidy you get. AHCA uses age. Obamacare assumes people with low incomes need more subsidies while AHCA assumes older people need more medical care and will need more subsidies. Just because you have a low income, does not mean you will need more medical care. Young healthy people starting out in life with have less money than older people with years of pay raises and promotions but who will have more health problems due to age. So it is not clear which method is better.

MySetDancer in reply to non-juror

Many political elites in the U.S. have for decades bad-mouthed European socialism as "evil" and almost "communist." Those of us old enough to remember the cold-war have a hard time shaking-off this propaganda. It is embedded in the Republican party and its minions. Poor people who don't get healthcare actually vote for these right-wing wackos!
As readers of The Economist, we all should know that countries like Germany and France cover everyone, have better outcomes, and spend around half the per capita GDP on healthcare as the U.S. How any rational individual can defend this arrangement eludes me. Seriously, I don't see how rational people can vote for politicians who defend this. And yes, I am a registered Republican.

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.

MySetDancer in reply to Kenneth711

Excellent post.

When I asked Kaiser Permanente for a cost estimate of an upcoming procedure, it took several phone calls and a very insistent tone in my "request" to get an actual dollar cost estimate. They clearly did not want to provide me with a dollar amount. Either (1) I am the first person in history to ask for a dollar estimate or range for a very, very common procedure, or (2) Kaiser Permanente management is plain stupid and do not track common procedure costs (unlikely), or (3) Kaiser Permanente is so incompetent that they really have no idea and really don't care (also unlikely). Overall Kaiser is OK, but sometimes I want to scream!

Best regards.

Just saying 597 in reply to Kenneth711

I think you're generally on target about the lack of transparency of the US health care market, but you pin too much blame on doctors. If you ask me how much a surgical procedure I perform on you will cost you, there are two big reasons that I can't tell you:
1. The amount I bill will have very little to do with how much I get paid, because (as you point out) each insurance company negotiates a different fee. And if you are uninsured, you will almost certainly qualify for a fee reduction from my office; if you are uninsured and it is not an emergency, we would work this out in advance, and you would certainly know how much it is; it will depend on your financial resources. However, almost nobody (maybe literally nobody) pays the amount of my standard bill out of pocket; the standard bill is almost meaningless, though I'm happy to share the amount with anybody who asks (nobody does). On the other hand, if you ask me what your out-of-pocket cost will be if you do have insurance, I still can't tell you, since that's between you and your insurance company (I don't know what your deductible and co-pay are). I suppose somebody in my office can look up the total fee negotiated with the insurance company, though the information is not easy to come by; in my case, I work within a large system, and the fees are not negotiated procedure by procedure; the fee schedule is even regarded as a trade secret, believe it or not. If you have insurance and you ask what the total doctor's fee is, we will inevitably refer you to your insurance company.
2. The amount that I get paid is a fraction of the cost of a procedure; the facility in which a procedure is performed charges for a lot more than the doctor's fee. I have no idea what the facility's fees will be (again, these will be very dependent on the particular insurance company), and these fees could potentially be affected by "complications" or, more accurately, by the post-op course. However, my fee is almost always unaffected by complications, since all post-op care by the surgeon for up to 90 days is covered by the fee for the procedure.

Kenneth711 in reply to Just saying 597

A good deal of the fault lies with the AMA rather than individual doctors. I think most doctors would rather the business end of their practice not exist because it can be such a hindrance on what they want to do, take care of their patients. However medicine is also a business and has to be run properly. Otherwise costs will get out of hand, often because the doctors do not pay attention to how much their tests and procedures will cost them and their patients.

MySetDancer in reply to Kremilek2

The rich don't pay for the poor's healthcare in any country I am aware of. They don't in the E.U. and they don't in Russia. A combination of mandatory health insurance and/or taxes pay for healthcare in most OECD countries. That is the way it should be. Once again, the "quite simple" answer is not quite adequate.


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 NdiliMfumu

But their proposal enforces another penalty. If your coverage lapses you get soaked if you buy coverage. It's a mandate but one that will drive the young from coverage, so destroying the very population that offsets sick and old.

Again American competitiveness remains maimed by bloated medical costs. For all that expense the medical system doesn't make Americans healthier.

Kenneth711 in reply to teacup775

This is a mandate that makes people buy health insurance BEFORE they get sick. Obamacare does exactly the same thing with its explicit mandate to buy insurance immediately or pay a tax penalty. The Obamacare method failed as the tax penalty was less than the cost of Obamacare for many people. It made more sense for healthy people to pay the penalty. This is simply trying a different method as the old method clearly failed. More importantly it no longer makes people into criminals for making a sensible decision. It only makes them pay if it turns out to be a bad decision but that is what normally happens when you make a bad decision.

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.

Kenneth711 in reply to teacup775

All decisions are a gamble unless you are a real fortune teller who can foresee the future. There is actually nothing counter productive about young and healthy people buying health insurance. Anyone can incur a medical expense at any time for reasons other than illness. You can break a leg skiing. You can get in a car accident. You can get food poisoning at a Michelin rated restaurant.

Deciding not to buy health insurance is gambling that you will never have an accident and never get food poisoning and never get Zitka while vacationing and so on until you are old. It is a bad decision but young people are known for making bad decisions.

guest-wommjjo in reply to Kenneth711

It's amazing how much progress Obama made on this issue considering the boat-anchor he had to lug in the guise of the tea party and republicans, who are functionally indistinguishable. The people who benefit from the ACA are people who have pre-existing conditions, not loafers or scroungers. If you want to help cancer victims, you have to pay the piper, by making the pools functional. A threat of a 30-percent increase in premiums to an uninsured 25-year-old probably has as much likelihood of influencing her/his decision-making as a promise of prime real estate in the first Mars colony.

Kenneth711 in reply to guest-wommjjo

The pre-existing condition problem predates Obamacare by decades and was a separate issue that was tacked onto Obamacare to get more support for it. The people affected by it were people who could afford health insurance but could not get it because of the pre-existing condition. The HIPAA law fixed that problem for most people. Only people trying to get insurance for the very first time were still being denied coverage for a pre-existing condition. So Obamacare only fixed the problem for the last remaining few people who had this problem.

"you have to pay the piper, by making the pools functional"...Much of the problems of Obamacare was the methods it used to pay the piper to make the pool functional was badly flawed. It mandated everyone had to buy insurance but made the penalty for not buying so low that many people found it was cheaper to pay the penalty. It enacted a medical device tax intended for expensive devices such as ICU life monitors but the definition of a "medical device" was so badly written that bandages were "medical devices". All these problems were due to Obamacare being passed without review for political purposes. So Obamacare shot itself in both feet out of the gate through the way it was passed.

In addition Obamacare increased the amount that had to be paid to the piper with politically inspired mandates. As an example, all Obamacare plans had to cover birth control. There are no birth control for men and menopausal women do not need birth control. However it was mandated for them and they had to pay the piper for that mandate.

Obamacare did not need the Tea Party or the GOP to be a failure. It was doing a good job all on its own.

guest-wowjlaj in reply to NdiliMfumu

So the federal government is responsible for providing more than 63% of all healthcare and they are the “800 pound gorilla in the room”. And the U.S. has the most expensive healthcare of any OECD country as a percentage of GDP. So it would seem that the main driver of that high cost is the 800 pound government gorilla, not the private insurance companies.

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?

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 !!

5ToNQXULG3 in reply to guest-wommjjo

It's not the 'avarice of doctors' but rather the way the whole system is set up in terms of payment for procedures, tests, etc. The US does pay doctors more than other countries (See this article:
A National Health Service would alleviate some of this issue as doctors and nurses would be paid the same everywhere, based on their seniority, training and the wards they work on. They would still get paid a decent salary, higher than average, as they do here in the UK. A chunk of that salary goes to pay for their education (much more expensive in the USA) as well as continual tests and training they undergo, and their own insurance costs (the US is a very litigious place). But, doctor pay is just one piece of the puzzle:


The article misrepresents what Texas does: it doesn't take for a family 15% of FPL to not qualify for Medicaid; it takes 15% of FPL for *adults* in the family not to qualify for Medicaid. Texas will cover children and pregnant women.

concussedx11 in reply to Sherbrooke

There are no consequences to the Corporate owned media for misrepresenting the truth. The only effective measure against them is to unsubscribe. The ONLY reason CNN still exists is because it is included with your cable subscription. Same with NPR, etc.

All by Orwellian design!

guest-ajammnjs in reply to Sherbrooke

Texas will cover children and pregnant women.
The problem is that GenXcess and GenYners have kids out of wedlock,
so Uncle Sugar pays.
MARIO MOLINA: Well, you know, the CBO has looked at this. And they have found that the most cost-effective way of covering low-income people is actually through Medicaid.
Medicaid accounts for 50 percent of all births in this country. One-third of all the children are covered under Medicaid, and it pays for half of long-term care. So it’s a big program that covers 72 million people.
It's a demographic thing,
you just wouldn't understand.

guest-ajammnjs in reply to guest-ajammnjs

The problem is that GenXcess and GenYners have kids out of wedlock,
so Uncle Sugar pays.

Are you sure?
WT Economist blames everything on the Baby Boomers.
Berea parents charged in 7-year-old son's heroin overdose
Charles Dowdy and Danielle Simko, both 31, are set to appear in Cuyahoga County Common Pleas Court Friday after a grand jury this week handed up endangering children and drug possession charges.


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.

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.

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.

concussedx11 in reply to MrJefferson

How did the system become so complex? Why do all successful socialized systems involve waiting periods that increase cancer mortality rates? Why is it possible for one to get bypass surgery in India for $1,500.00 rather than $100,000.00 in the US (& with a better mortality / success rate)? The obvious answer: Government rationing of a system distributed by cartel pricing.
Cronies are protected by govt. bureaucrats who thrive on campaign "contributions" (bribes). This is why (under the ACA) Washington DC has the choice of 16 plans offered by only 4 allowed participants (cartel). The State of MD has even less options. Add on to that the reality that the mega provider's Attorneys of Record keep being appointed to direct the very regulatory agencies designed to reign in their employers & the soup becomes toxic.
THERE ARE NO UNINTENDED CONSEQUENCES! "Apathy toward political affairs insures the rule of evil men." - Plato (Loosely)

Mark235 in reply to MrJefferson

I used to work at the federal Department of Labor and there is a key point to the way the Consumer Price Index (CPI) is calculated for some major expenditure categories such as health care and home ownership that isn't understood by the general public. In the case of health care, the CPI is calculated based on the payments made to medical providers and does not consider the cost of health care premiums under the argument that it is too difficult to measure costs on an apples to apples basis at the premium level because of the significant differences between insurance policies. So, if all health care insurers due to say purchasing power cut the reimbursement rate to doctors, hospitals, etc. in half but doubled the premiums to every policy holder the CPI would show a decline of 50%.


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

Sherbrooke in reply to Barracuda008

Obamacare's biggest issue was misunderstanding Romneycare.

Romneycare pulled people with subsidized policies (under 300% of FPL) into the same people who get Medicaid, meaning that Medicaid office will have to provide policies and keep costs down. The poor ended up being among the sickest people out there.

Obamacare instead mandated that these same subsidized people be part of a common pool, which raised insurance rates for people who had to buy it. Even more, not only it created a situation when insurance companies end up with mandate for coverage, but fewer ways to control cost - the subsidized bunch ended up with no financial disincentives to use less healthcare, as most deductables ended up being subsidized too.

As things stand with Obamacare right now, the high-deductable silver plans cost millions of Americans a lot more than Feds spend to cover Medicare patients. This is an outright failure.


The easiest plan: Scrap Obama-Care. Don't replace it. The free market will take care of the rest. The markets for cars, houses, travel, mobile phones, auto insurance and a hundred other things function well without the government getting involved.
The Economist criticises subsidies of fuel in Nigeria, rice in India and all sorts of other things in other countries even though the poor like them. Why does The Economist go weak at the knees when it comes to criticising health care subsidies in America? Subsidies always distort the market.
Health-care has become unaffordable because governments offer to pay for it. When the cost of something is passed on from the end-user with modest means to a government which offers to write blank cheques, it is the perfect set-up for prices to rise endlessly regardless of whether the prices are realistic to end-users of the product or service.

guest-ajowmemi in reply to L-gharef

I agree with you wholeheartedly. When hospitals know that insurance companies will foot the bill they charge with massive increases. I have talked with people who have paid their medical bills with cash at close to a 1000% discount compared to if the hospital would have billed insurance. Then, insurance companies do not care because they will increase premiums or look for subsidies from the federal government to foot the bill. If we really want to fix healthcare, I believe, that this is where we start. Control how much hospitals are allowed to charge to insurance companies compared to charging for cash. When this disparity falls, the market will level out.

L-gharef in reply to guest-ajowmemi

In the Finance & Economics section of this week's print edition, The Economist has an article about an experiment which suggests that when taxi-drivers are aware that a third party is paying for the ride (say, a boss), the taxi-driver charges considerably more than if the person taking the ride were the one who is actually paying.
The more you distance a a payment from the end-user of a product or service, the more prices spiral out of control as providers seek to make a killing while users pass on the cost without a care in the world.

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.

guest-ajammnjs in reply to L-gharef

The Economist has an article about an experiment which suggests that when taxi-drivers are aware that a third party is paying for the ride (say, a boss), the taxi-driver charges considerably more
Look at all of the silly freebies the tech industry gives its employees.
TYLER WILLIAMS: So, we put these games on the elevator to hopefully …
TYLER WILLIAMS: That was good — to hopefully stop and play the game, have collisions, have conversations, and get off on the wrong floor, so people would visit different areas that they normally wouldn’t.

Melissia in reply to L-gharef

Problem: The "free market" does not naturally exist.

it is a hypothetical "best case scenario" for economics, and economic theory requires government regulation in order to ensure that a state as close to it as possible can exist in reality.

Kenneth711 in reply to JKPbody64

Medical care in the USA is mostly a dark market, not a free market. In a dark market, all transactions are legal and freely done as in a free market. However no one outside the direct participants know what transaction was done, what the price was or even that a transaction was even done at all. A free market only works when everyone knows the transaction has taken place and for what price so when someone else makes the same transaction, they have a better idea of what it is the proper price.

So when you go to a doctor, you have no idea what other patients paid that doctor or what other doctors charge for the same service. The doctor can charge every patient a different amount based on the income of the patient and that is exactly what they do. People who pay themselves get charged a lower fee than people who have insurance because the insurance company can afford to pay more.

wet coaster

They are building a very complex and possibly unworkable system worthy of Rube Goldberg. I wish he were still around, one of his drawings might help explain it to me.