2013

Changing the ACA incentives to maintain continuous coverage from a penalty for months when you don’t have coverage to a retroactive penalty enforced when you try to sign up for coverage after having no coverage is not a huge change. I would argue that it’s just re-arranging deck chairs. However, in the spirit of compromise, let’s say that I stipulate that the BCRA penalty system is equal or better than the ACA penalty system and I will agree to it. Even in that situation, it is a small change.

Does the BCRA offer anything else that meaningfully extends affordable access to good quality coverage over the ACA?

I believe that the chances for bipartisan compromise are nil. The GOP blew that chance to hell in 2009 and until there is major change in the GOP, there’s no putting Humpty Dumpty together again.

2014

From a political standpoint, that may be true. It certainly will be true as long as the GOP (particularly the House) considers the interests and votes of non-republicans irrelevant, due to gerrymandering, the Hastert rule and the conservative media’s obsession with idealogical purity. I don’t know whether this is fixable, short-term or long. Personally, I think it will get worse.

But McConnell has said on several occasions that, if repeal failed, they would do something to stabilize the insurance markets in the short term. Why? This contradicts the strategy Trump (and Lindsey Graham) espouse, of letting the ACA death-spiral happen, or even causing it. Does McConnell actually care that this would result in actual people going bankrupt or dying?

I doubt that. I assume he is making a purely political calculation that the GOP will get the blame if the markets implode. The media coverage would be pretty dramatic, when they start covering child cancer patients who’d lost their insurance, etc. So, maybe there is room for some small areas of mutual interest. Maybe the GOP does want to avoid dead Americans, even dead poor Americans, if doing so benefits the GOP.

But probably not. You’re probably right.

2015

It’s like all the voters have amnesia as to what Obama took over or just wrongfully assumed it would have gotten better no mater who was in charge. That’s a terrible assumption to make.

Both are designed to prevent people gaming the system, waiting until they are sick to buy (or upgrade) their insurance. People who do this raise rates for everyone else.

Yep. To keep these pools viable, the healthy have to pay. They will whine about it the entire time, but you need everyone participating, even the kids who think they have a right to gamble with the ER.

2016

And this, of course, is why an “individual mandate” (either in the in the form of a contemporaneous or a retroactive penalty) is a pretty poor idea, compared to simple automatic enrollment. It’s kind of bleakly hilarious that the GOP chose the individual mandate to attack in 2009 when that was actually a compromise offered by Obama instead of the more effective yet more liberal automatic enrollment.

The GOP has only 2 options on health care: 1)they could maintain a hard conservative line that the government should not provide health care or help people obtain healthcare and that all healthcare should be 100% market based. Due to the inelasticity of demand and the fact that health care is a flat expense in an unequal world, this would leave tens of millions of Americans without good health care access. This would be the pure conservative market position. It would suck rocks but it would be honest. It would also lose the GOP every election from dog catcher to President. 2)They can embrace moderate to conservative health care reform along the lines of the Swiss Model, with options ranging from “weak Swiss Model” like Romneycare/Obamacare, through “weird Swiss Model” like Singapore, up through “strong Swiss Model” like Germany or France. German and French systems are almost certainly a bridge too far for the GOP, but if they were a reality based conservative party actually dedicated to improving the lives of Americans they would embrace a plan like the ACA. But for a variety of reasons, they crapped upon the ACA. They have deprived themselves of an ACA type option, and they also don’t want to eat the electoral pain of saying “the poor and old can suck market weenie for health care” so that leaves them with… nothing.

Sure, there are some things that could be done to stabilize the ACA as a stopgap, and maybe that will happen, but in terms of substantive health care reform, the GOP is either going to continue to eat crap, or eventually (perhaps due to a party split or vast electoral defeat) admit they were wrong about the ACA (or at least redefine the terms so that an “Don’t Call It Obamacare!!!” system can be embraced.)

One of the funniest things is that Trump apparently is still not in on the reality. He appears to think that magic market mushrooms can fix health care (they cannot b/c inelastic demand.) For example he tweeted recently about doing away with the filibuster so the GOP can allow selling insurance “across state lines”, apparently under the impression that this is currently not allowed (it is allowed) and also that “increased interstate competition” will be the magic bullet. That’s…, well that’s a topic that requires another post.

2017

Since Trump is raising the idea of “selling insurance across state lines” again, let’s discuss what the deal is with that.

I put “selling insurance across state lines” in quotes because it is very disingenuous. Ostensibly this is an idea to increase competition in health insurance which will, via the magic of the invisible hand, produce better coverage at lower premiums. In reality this is a plan to deregulate health insurance nationally.

The deception on this issue is profound. When we read “allow health insurance to be sold across state lines” most people assume that this implies that it is currently illegal to sell health insurance across state lines, which is false. Plenty of Americans will absorb this false meaning, often facilitated by pre-existing biases that there is “too much regulation” etc. However, we do in fact have interstate commerce in the US; it is a major pillar of the underpinnings of the Union after all.

Health insurance can currently be purchased from out of state insurance companies in every jurisdiction in the US that I am aware of. For example, in my field of workers’ compensation (which is about 40-50% convergent with health insurance), about half of my cases in recent years have involved workers’ comp insurance sold in CA by out of state companies. AIG sells their CA work comp policies out of Shawnee Mission, Kansas. Liberty Mutual sells their CA policies out of Beaverton, Oregon. Meadowbrook Ins. sells their CA policies out of Las Vegas, Nevada. And there are many other examples. In terms of personal health insurance, in prior years I had policies from Aetna and Cigna which were sold out of CT. Right now, I’m on Aetna again, and again the policy is sold out of CT.

So, if health insurance can currently be sold across state lines, what does the GOP mean when they say they are going to “allow” it? I mean, it’s already allowed. Well, the wrinkle in interstate commerce in the US is that out of state companies can sell products and services in any state, so long as the product or service is legal in the state of purchase. And that requires the product or service to comply with the laws, and the regulations, of the state. So, under current law, if an insurance company has a policy which legal in an insurance friendly state like CT or a corporate friendly state like Delaware, they can only sell that policy in CA or NY if the policy also complies with the laws and regulations of CA or NY.

In recent years, many states have imposed a variety of requirements for health insurance, while other states have a much more “Wild West” approach. The ACA has a set of minimum requirements for plans to be sold on the exchanges, which mirrored many of the regulations in the blue states. Repealing the ACA will do away with that, which means we return to the state by state approach to regulation. And then if we “allow insurance to be sold across state lines” (which really means a policy legal in any state can be sold in any other state), then the state level regulation is completely demolished.

First of all, for the conservatives who truly do believe in limited federal government and federalism, this is a massive pre-emption of state regulation by the feds. It basically means the regulations of the least-regulated, most pro-corporate, most pro-insurance states becomes the law for ALL states.

So this proposal is highly deceptive. It is also a very bad policy as it will enable the following laundry list of insurance company shenanigans (disclaimer I’ve represented insurance companies in work comp for 20 years so I am both a black hat and also pretty damn knowledgeable about this stuff):

Some states allow lifetime benefit caps,which means a policy could say “once we’ve paid $500,0000 or $1,000,000 lifetime, we pay no more”. If you get a really nasty health break and blow past those caps, you are screwed.

Some states allow caps on benefits “per condition” which means a policy could cap benefits at $50,000 or $100,000 for a “single condition”. Which means if you get something nasty like cancer or something really chronic like insulin dependent diabetes, you are screwed.

Some states allow caps on certain categories of treatment. For example, prior to the ACA there were a number of articles about policies with $2,500 or $3,000 caps on the costs of a birth, at a time when births were averaging $15,000 to $20,000. Which means even if a family was “covered” they could eat $15,000+ in birth costs. If you are a member of a young family having a baby without substantial reserves and this policy kicks in, you are screwed.

Some states allow exemptions and exceptions for carriers to not cover certain conditions. For example, some policies used to exclude care for drug and alcohol issues, and even for mental health issues more generally. If you have a serious problem requiring psychiatry, you are screwed.

Some states allow mandatory forum selection clauses, which means if you don’t like something your insurance did, you have to litigate the issue in their home state. If you don’t have the bestest evar case or the big bucks to retain an out of state attorney willing to take on a hometown defendant in a state where the laws favor insurance companies, then you are screwed.

Some states allow mandatory arbitration clauses which means you lose the right to sue and any disputes must go to an arbitrator and since the insurance company has vastly greater experience and influence with arbitrators, they will win about 85% of the time. In other words, if you want to sue your carrier, you are 85% screwed.

Some states allow “catastrophic policies” which only kick in once your costs exceed some high amount like $50,000. For most people, having to eat a big loss like that up front means bankruptcy. So health wise with a major condition, the coverage will save your life, but financially (say it with me now) YOU ARE SCREWED.

People who understand insurance and healthcare have known for years that “selling insurance across state lines” was both deceptive and also a facade for insurance deregulation. But the GOP keeps trotting the zombie horse of an idea out, probably b/c they have nothing else.

For Trump to be trotting this zombie horse of an idea out now shows that the GOP really has nothing to offer on health care.

2018

Thanks for the highly informative posts, @Sharpe. Not just these last two but pretty much all the stuff you’ve posted in this thread.

It’s pretty sad that you can say this about just about every issue and it’s true.

2019

@Sharpe, I would like to say this in a more useful, less crude way, but I just woke up from a deeply necessary nap and your words are basically the first thing I saw after doing so and your last 3-4 posts in this thread are the sexiest goddamn thing on earth right now.

2020

Will you please stop saying this. Sharpe, you are a sharp guy, this doesn’t help your credibility.

Celelari’s link is one of 1/2 dozen different source that I’ve seen that have said similar things.
Romney was pragmatic governor in a deep red state. He isn’ the first Republican to advocate for increased government benefits (see Bush 43 and Medicare part D). He signed the legislation because he had little choice as Celeria says 8 part he vetoed were overridden.

Regardless of the origins of ACA, by the time the bill was being shoved through by the Democratic leadership, there were no conservative principals left. (Once, the 3rd red state implements single payer I’ll retract that to add other than private insurance). By definition, a bi-partisan piece of legislation has the support of both parties. ACA didn’t receive a single Republican vote. Trying and spin it as bi-partisan is to venture in Alt Reality world of KellyAnne Conway.

I believe I’m one of the most bipartisan folks on the forum, I’m confident that I’m the only person who voted for an almost equal number of Rs and Ds and a libertarian in the last three elections. (One more Republican total). I can tell you that short of having a gun to my head, there is no way I have voted for ACA. In fact, if I had a time machine and I could go back in time I’d have contributed money to trying to kill it. This isn’t because I watched too much Fox news, was ignorant of ACA, or am even opposed to government helping poor people get health care. It is just an awful bill for reasons which I have discussed in many posts.

Never the less Obamacare is the law of the land, and the only way to keep our ridiculously inefficient health care system from getting worse is to fix it in a bipartisan fashion.

2021

You mean a deep blue state, right?

2022

OK Strollen, how? How do you fix Obamacare in a bipartisan fashion?

From my point of view, the problems with Obamacare, in order of immediate need to longer term need, are as follows:

1)In the immediate term, the health care exchanges are currently somewhat unstable, primarily in red states and counties, and also there are some areas of the country that lack sufficient competitive plans to provide good affordable options.

2)In the interim term, one of the main complaints about ACA plans from exchanges is that co-pays and deductibles are too high.

3)Another complaint is that the subsidies phase out too low and many middle income Americans are left struggling to afford even cheap plans on the exchanges.

4)In the long term, the ACA still leaves roughly 28 million Americans uninsured, roughly 9% of the population. Although some of those are by choice, based on the number of Americans still needing care despite not having insurance, many of that 28 million are uninsured b/c they can’t afford it, or b/c they are just flat wrong about not needing it.

5)Also in the long term, and this is probably the single biggest issue, there is the problem of health care price by which I mean the fact that the prices for goods and services in US health care is roughly double the average in the developed world. In addition, health care prices have been rising faster than the rate of inflation for decades and the current projections are that although the price curve may bend down, it’s still projected to be higher than inflation for more decades.

I’ve already made my liberal proposals clear:

Option1) beef up the ACA with stronger subsidies and coverage requirements, add a public option, add in all-payer pricing, and pay for the subsidies with taxes on households making over $400K per year (you could probably pay for what I suggest with a bump of the current ACA earned income tax on $400K plus from 0.9% to 1.5% and the capital gains tax bump from 3.6% to 5%).

Option 2)Go with a phased in single payer (something like the old Americare plan with some updates), paid for with a combination of payroll and income taxes. The taxes would be superficially stiff, with my proposal at 4% payroll tax for employees, 6% payroll tax for employers and 8% marginal rate increase in income tax (both earned income AND capital gains) for households over $400K. The reason I say these tax increases are superficially high is that US employees already spend roughly 5% of payroll on premiums, co-pays and deductibles, and US employers already spend about 7% of payroll on health insurance. So my plan would actually cost employees and employers less on average. The difference, plus the cost of covering the currently uncovered 9% of the population, is paid for by the 8% bump on high incomes. However, this plan would have winners and losers as some people currently pay more or less than these averages, which would create severe political opposition. So I tend to believe that although single payer is simpler and more efficient long run, we have more chance of implementing option 1.

Bottom line is, those are 2 solid options, similar to very successful systems in other countries, and they actually have roughly balanced numbers and strong evidence they would work in the real world.

So if there are bipartisan alternatives that would actually work to retain and expand good quality coverage for most Americans, what are they?

I don’t mean that snarkily. I’ve put my ideas on the table. What are the alternatives?

2023

Also, Strollen, on the whole bipartisanship issue, the fact that the ACA did not get a single GOP vote does not mean that it was not substantively bipartisan, in an honest, real world definition of reasonable bipartisanship.

See my thoughts on this here

The fact that the substantively moderate ACA proposal, which contained mostly moderate ideas with some liberal ideas (progressive subsidies based on income) and some conservative ideas (individual mandate) did not garner a single GOP vote is not a sign that the ACA was tainted but rather that the GOP was tainted. The GOP had a golden opportunity in 2009 to participate in a bipartisan health reform process and they refused, falsely labeling the ACA as socialized medicine, deceptively focusing on the gaps and flaws to exaggerate problems, and flat out lying about “death panels!!!” etc. Not only do I not accept their bad faith partisanship as showing the ACA was overly partisan, but I do not forgive their offensive deceptions, their attacks on the truth, and their grotesque political manipulation of the flaws in the ACA to slam Dems and gain political power.

There’s a whole substantive argument here about bipartisanship, but then there’s a second thing:

For the GOP to want bipartisanship NOW, after saying for years that Obama was a socialist unAmerican Muslim, after attacking Dem Congress people in 2002/2003 as traitors and wimps for not supporting the Iraq war, after blocking more Obama appointments and more Dem legislation from 2010 to 2016 than ever in history, after refusing to even give Merick Garland a goddamn hearing, after stealing Obama’s 2016 Supreme Court nomination, after suppressing votes in many states, after what-ever-the-F craziness is going on in North Carolina, is ridiculous.

It’s like someone viciously attacking you, beating you up, taking your stuff, and then saying, “OK let’s stop fighting now”. NO, MFer, why don’t you give me back my stuff, and why don’t you make up for all the damage you did, and let’s also take you off the political street for a few years for violating the norms of civilized behavior, then maybe we can talk peace.

If there is a splinter or remnant of reality based GOPers with integrity who is willing to work with Dems, great. But right now, the main bulk of the party has decades of ugly karma to repay before we get to bipartisanship.

2024

Thank you so much @Sharpe. I read the whole she-bang aloud to my wife and we both learned a lot.

2025

They aren’t going to give up, they will keep trying until they do SOMETHING… ANYTHING they can claim counts as repeal. It is urgent that Dems get going publicly with proposals and meetings and offers to get involved in what comes next, because if Repubs have a chance to do it all on their own they will still do it.

2026

This ain’t gonna work, dude.

I mean, what do you expect them to do? What’s your ideal action for them to take?

2027

I think it’s more that the rest of us need to stop playing their stupid games, stop playing fair, and dump all over their agenda for a few decades.

Mind you, for that to work, the fraction of America made up of people who AREN’T complete assbags needs to start actually voting…

2028

In terms of what is realistically possible, I don’t see any positive options until the GOP is severely beaten in multiple election cycles or until the party splits.

In an ideal world, I would love to see the GOP reform itself into a reality based fiscally conservative party, skeptical of overreaching authority. That, for many reasons, is just not going to happen without major change in US politics.

As a second option, I would like to see the fraction of the GOP that has not gone completely over to an alternative reality/extremist point of view split from the GOP. I don’t see a realistic possibility of the non-extreme GOP retaking control as the extreme/alt right/talk radio faction is a substantial majority of the GOP, in the range of 70% to 80% of GOP general election voters and 85% to 90% of GOP primary voters. That extremist lock on the primaries means the GOP probably cannot reform itself short of major generational electoral defeat or a major party split. Unfortunately that 15% to 30% of the GOP which is still in touch with reality would by itself be a small minority party in the US and with our winner take all elections, they would have near zero real power. So I can’t really imagine the GOP splitting until it has already lost power.

That leaves us with the third option: the GOP has to lose, and lose, and lose, until it breaks. I understand that is going to be a massive electoral challenge, but it’s the only viable option, If the GOP clings on to majority or even substantial minority power, it’s going to be a long ugly process. However, the GOP has proven, that since it passed the point of no return (IMO sometime in the late 90s) it cannot govern at the national level and will continue to worsen the severe issues facing America, until it either destroys American democracy, or is destroyed BY American democracy. I am hoping for the latter, obviously.

Look, I wish I could give you a more sanguine Kumbayah answer but man, the GOP has been attacking liberals, calling us traitors and wimps, lying on every damn issue, endorsing racist and authoritarian leaders, and just generally being a bad political actor for a couple of decades. And unfortunately due to the makeup of the GOP, the fraction of the GOP that is not that bad just has very little power. They can (as with the recent ACA repeal) temporarily halt the GOP train, but they cannot divert the train onto a less destructive path over the long haul. The internal logic of The Long Con, the incentives of outrage and fear driving website and talk radio ratings, the reliance of the GOP on outrage and fear to motivate voters, and the fact that the non-extreme faction is so small now (most of the less extreme GOP having already bailed) means the GOP cannot reform itself.

In the long run, despite the short term electoral success driven by the Right Wing Media Machine, Rush Limbaugh, etc., in the long run I sincerely believe that future historians will consider Rush et al. to be the worst thing to ever happen to the GOP. Either my hoped for outcome will occur and the extremists will end up leading the GOP to failure and collapse, or they will collapse US democracy. Either way, the old GOP, which was a party that believed in democracy and despite my ideological disagreements was also a party with views in large part based on reality and sanity, is going to die. The inmates have taken over the asylum and they are either going to burn the asylum down or burn the rest of us down.

I mean, what option is there? Is there any way for the modern GOP to reverse itself on taxes so the US can bring in the revenue necessary to be a truly 21st Century First World nation? Is there any way for the GOP to reverse itself on health care and actually improve coverage and healthcare prices in the long term? Is there any way for the GOP to reverse itself on excessive military spending and bring our wasteful defense budget down to just triple or quadruple our closest rival instead or sextuple or septuple? In the big picture, is there any way for the GOP to stop relying on fear and outrage and still win elections? I don’t see it.

Again, I have asked, how many times, WHAT IS THE BIPARTISAN ALTERNATIVE? What is it?

2029

So then you expect nothing productive to be done by the government for MULTIPLE election cycles.

That’s your plan.

I mean, I agree that the GOP is terrible now. But the idea of punishing them for past transgressions rather than even being open to compromise isn’t a productive path forward.

2030

OK, dude, either answer the question, or stop pestering me: WHAT IS THE ALTERNATIVE? Give me a few examples.

2031

I think Robert’s arguing that the electorate has to wake up to the reality of what the GOP has become and cast them out into the wilderness for a decade or more. The GOP, if facing that loss of power, might just reform itself. Otherwise we continue on the current path, which is on a rather sharp decline.

2032

  1. Thank you for the posts today Sharpe. They’ve been smart, cogent, and argued brilliantly.

  2. You’ve asked what the “bipartisan alternative” is. I think I know what it is…and it isn’t bipartisan at all in practice, just in presentation.

I keep thinking about this the way I would if I were suddenly made a director of the RNC and had to fix this mess for the Republicans. And the only way forward I see that makes any practical sense in the short term is this: you make a big deal about how the ACA is struggling across a couple of different vectors…and then you announce that you’re going to do something to protect the healthcare of millions until a permanent Republican solution (which you know isn’t coming) can be implemented.

And then you tell Red hold out states to take Medicaid expansion. You kick money into subsidies and exchange pools as needed to shore those up.

And then you tell everyone that the ACA was falling apart, and YOUR PARTY saved it. That the Democrats’ 2010 plan was about to create a human rights disaster, and the Republicans stepped in and fixed it. And then you defy Rand Paul to do anything but suck it.

(And Democrats just say “Sure, whatever dudes, this is great” and still frame it their way for their constituents.)