Interesting argument here

On Tuesday, Donald J. Trump said he wanted Congress to repeal the Affordable Care Act right away and replace it with a new plan “very shortly thereafter.” But before they abandon all the work that has gone into the health care law since 2010, President-elect Trump and Republicans in Congress owe Americans a detailed explanation of how they plan to replace it. They should not repeal the law until they have submitted their replacement proposal for analysis by nonpartisan authorities like the Congressional Budget Office and the Tax Policy Center to determine how it will affect health insurance coverage, state and federal finances and individual tax burdens.

Vague promises are not enough when we are considering enormous changes in this country’s $3 trillion medical economy.

Vague promises aren’t enough, just as they weren’t when we had to pass the law to find out what’s in it?

26 comments on “Interesting argument here

  1. Amazing! So the US had no medical economy before Obamacare? Incredible! So all those hospital dramas we used to watch on Brit TV in the 70s were sci fi/fantasy niche?

  2. I’m *loving* the media openly criticising Trump for wanting to do exactly what Obama did.

    Cf. the political ambassador “clean sweep” – according to the media, it was a good thing to clear out Bush’s dead wood in 2009, but now it’s sob stories about some donor-ambassador whose wife has cancer, and another whose kids are in school, so how could Trump possibly do a clean sweep…

  3. They always have to replace crap with some more crap. Why can’t they just completely repeal crap and go back to exactly the way things used to be before the crap was enacted in the first place?

  4. There’s virtually nothing Trump could do that he couldn’t point to Obama or Clinton (male or female) and say ‘Well they did it first’. The Left is hoist on its own petard, they’ve allowed ‘their’ politicians to behave with little regard for the law, now they’ve got someone they don’t approve of in charge, and now there’s no law left to stop him doing the same………

  5. So we also need more checks on the President’s right to authorise drone strikes then? And more oversight of his right to authorise surveillance? How about more oversight on all the things abiut which Barack Obama thought he should just be allowed to get on with it eh.

  6. Granted that the US health careuniverse is a mess.
    Before Obamacare, you generally got health insurance to pay for your health care. Normally from your employer or (if over 65 or disabled) from Medicare (or if extremely poor, MedicAid).

    The insurance coverage for those employed was generally that of “group insurance” – you couldn’t be refused, or dropped, or have your premiums increased because of your health situation.

    Those who weren’t crippled up enough or old enough or employed enough had to either run naked through the healthcare forest hoping for no tigers (I feel poetic today, imagery-wise) or seek to purchase private health insurance, which was essentially never provided on group terms, but on individual terms.

    So you could be refused; your coverage could include consideration of your health history, which would affect your premium; your premium could increase if you had a health problem; you could be refused coverage at your next renewal.

    Not a good thing at all. If the Republicans just ‘repeal’ Obamacare, they’ll be dumping the sweaty masses back into a bad situation. Which is not a good thing.

    ObamaCare basically says two major things : all health insurance is group health insurance; oh, and you have to have it or we will fine you. (The fine was presented as ‘not a tax, oh no!’ but of course it is).

    It’s also possible that it contains language which in essence rewards health care providers for getting better results rather than applying more treatments (but I don’t know whether that’s part of the act or an associated one).

    It also has fairly ‘gold plated’ requirements for the insurance coverage – you can’t get minimal, or catastrophic coverage under Obamacare (you can still get it, but it’s outwith the reach of the law, so it’s individual), and thus the insurance is fairly expensive. And if you’re poor enough, you can get some money from the gummint to help pay the premiums.

    Thus far, Obamacare seems a vastly complicated mechanism for getting group term health insurance to “everybody”.

    I suspect the Republicans could come up with a simple equivalent which is four separate acts:
    – if you offer health insurance to anyone, it is on group terms
    – the government will include cost of health insurance premiums in its computation of how much money to hand over to the poor, with the intent that sufficient relief is offered that about the same number of people will be covered at about the same cost as under Obamacare
    – entities which provide health care must provide evidence that they are following best practices in care, with those being found to cheat/lie/fuck things over being subject to truly punitive fines
    – increase taxes a teensy bit to pay for it all

    The first three are pretty straightforward. The last one will stick in the craw a bit, but should be swallowable.

    This could be done pretty quickly, and it would have essentially the same coverage as Obamacare at about the same price, but it would be four independent (but coherent) acts which can be separately tweaked, and it would indeed be a repeal of Obamacare.

    Then, with that in place, they could consider what healthcare should look like. I’d get rid of (by tax-oriented implicit pressures) employer-provided health care. It distorts enormously. And currently, the money your employer spends on your healthcare isn’t taxable as income, while the money you use to buy Obamacare is taxed money; that needs to go (it may be that this change pays for the gummint help to the poor)

    I’ve probably got details wrong, but thats the big picture, I think.

  7. BlokeIn Tejas

    Thank you for the analysis. It’s good to something deeper than”You’re trying to murder grannies” “yeah well, you’re a commie”

    That said however, I am going to stick for the moment to looking at the double standards employed by the NYT and by Obama himself to analysis of his actions and of Trump’s.

  8. Repeal.

    The idea that ‘replace’ is needed says that Obamacare was needed, just done differently than they would have done it.

    Junk it. DO NOT use is a basis for an anal examination of the health care industry. No one I know wants to hear, “Well, what did Obamacare do?”

    Give Obamacare the Carthage treatment it deserves. Don’t get bogged down in details; kill the beast.

  9. Here’s a frivolous proposal for the US.

    (i) Whenever possible rely on free market mechanisms in health care.

    (ii) But accept that it would be wise then to have subsidies for the poor. These would have to be designed by people who understand the effects of incentives on us mortals.

    Of course, such a scheme would be utterly intolerable to every vested interest.

    Hell, even a proposal of “copy Singapore” or “copy France” would get the bum’s rush. Which is why I shall never have the cheek to make a serious proposal to Americans: there’s not the least chance that I’ll understand the interplay of vested interests. (Except one proposal: don’t copy the NHS.)

  10. Gamecock – “Give Obamacare the Carthage treatment it deserves. Don’t get bogged down in details; kill the beast.”

    The problem is that CNN is already wheeling out the poor telegenic young women with cancer that Trump wants to die slowly and painfully. I expect we will see a lot of this over the next four years. It won’t play well as White people are just too nice for their own good.

    dearieme – “Hell, even a proposal of “copy Singapore” or “copy France” would get the bum’s rush.”

    I am not sure. I think if you sold the Americans a scheme where the government would provide insurance for all the unforeseeable medical problems – cancer or being hit by a bus – but individuals had to provide for all the conditions that were routine or could be foreseen, I think the voters would agree.

    It is the distinction between the Deserving and the Undeserving again.

  11. Strangely, I don’t remember any howls of outrage emanating from 620 Eighth Ave. (the parts that hadn’t been sub-let, I mean) when Nancy Pelosi stated that Obamacare would have to be passed for anyone to find out what was really in it.

    If the NY Times didn’t have double standards, it wouldn’t have any standards at all.

  12. Dennis

    While Pelosi did indeed make that statement, there is some contextual evidence that she meant something more along the lines of – we’ll need to get it into operation for folk to see the goodness we engineered into it.

    That is, 2000 pages of guff doesn’t paint a clear picture of the real advantages this will bring.

    I’m prepared to believe that.

    But what rankles me is that they created a vastly overcomplex bill which was deliberately not discussed and forced it through. This is not honest behaviour, even were it to be a majestic Work of Art and bloody magic and made a Huge Difference.

    As I’ve noted, it did good, but it sure as hell wasn’t the magic change of life for the American health system. So I’m all for replacing it with some measures which do fix real problems (uninsured people is a real problem) and do so in a simple easy to udnerstand (from all angles) measures.

  13. “If the NY Times didn’t have double standards, it wouldn’t have any standards at all”: every time I see that remark I enjoy it.

  14. While Pelosi did indeed make that statement, there is some contextual evidence that she meant something more along the lines of – we’ll need to get it into operation for folk to see the goodness we engineered into it.

    Bullshit.

    Hers was a clear expression of both arrogance towards the electorate and cynicism about the legislation itself.

    Obamacare was never about “fixing” health care. It was about nationalizing a huge portion of the economy to expand the pool of unionized government workers (and Democratic Party voters). Obamacare only made sense if it lead to the adoption of a single payer system.

    “This is what you’re getting, peasants, whether you want it or not…”

  15. What DtP said above. Anybody who ascribes pure motives to Nancy Pelosi just isn’t paying attention.

    Also, to complete the picture provided by BlokeInTejas: the difference between the highest allowable premium and the lowest premium for the same plan is capped at some multiplier. This means that young people, who have no great need for health insurance in general, are in effect subsidizing older people when they buy insurance through an ObamaCare exchange. This is bad policy in itself, since young people are typically less well-to-do than older people.

    However, compounding the issue, one of the features of ObamaCare is that no-one can be refused coverage when they apply for it. The easily foreseeable effect is that young people do not buy health insurance and wait to develop an illness, at which point they apply for insurance. This is what the famous death spiral is about, with the pool of insureds being significantly older and sicker than any of the insurance companies that participated in the exchanges had anticipated.

    (Sure, not buying health insurance means you have to pay a fine – but since the fine is less than the insurance premium, it’s not much of a deterrent.)

    I described the disincentive effect above as being easily foreseeable, but of course that would assume a passing familiarity with real life, which the framers of the law evidently lack. I remember an op-ed that Ezekiel Emanuel (one of the “brains” behind the law) wrote in the WSJ, in which he complained that the people who were supposed to pay for the law (basically young males) were refusing to do so by not purchasing insurance in the first place. One can only say, duh.

  16. Furthermore, the “fine” that I mentioned above works as follows: if you overpay your taxes during the year, the IRS can assess the fine and just not send you all of the the money back in your tax refund after you file your taxes. However, the IRS is precluded from dunning you for payment of the fine – since that would in effect make it a tax, and it’s not a tax (unless it’s a tax, of course – the Supreme Court really contorted itself into a pretzel with their reasoning on this one). What this means is that if you engage in a modicum of tax planning and do not overpay your taxes during the year, then you can escape the fine altogether.

    So again, not much of a deterrent.

  17. Actually, having done a bit of googlemancy, I confess to having sold Ezekiel Emanuel short in my diatribe above. He did foresee (on May 6, 2013) that young men, whom he called the young invincibles, would likely forego insurance because it wasn’t a good deal for them, which would cause the insurance pools to skew older and sicker than required to make things work out.

    His solution: (1) have Obama talk to them; (2) have society talk to them; (3) have baseball players talk to them.

    Relevant quotes in the link above, in case you think I’m making it up:
    (1) “The president connects with young people, (…) so he needs to use that bond and get out there to convince them to sign up for health insurance to help this central part of his legacy.”
    (2) ” The social norm of individual responsibility must be equated with purchasing health insurance.”
    (3) “One aspect of the campaign focused in particular on young men, even heavily promoting the new exchange [for the precursor of ObamaCare, the healthcare reform introduced in Massachusetts by Governor Romney] on TV during Red Sox games and hosting an annual “Health Connector Day” at Fenway Park.”

    So everything went as planned in the end, I guess. Brilliant propaganda effort by all concerned, and probably one of the things that gave us Pajama Boy.

  18. Bit like here where young drivers pay through the nose for car insurance to subsidise the older drivers?
    Back when I were a lad I had to get my dad’s insurance on my car. In my own name the annual premium was more than I purchased the car for.
    My first accident was 5 weeks after buying the car – a car overtaking on a hill suddenly coming towards me on my side of a road and no way to avoid them.
    My 2nd accident was several years later when a 15 year old reversed a van down the street and slammed into several cars, requiring a lot of repair to the car I had at the time.
    Obviously 15 year old had no van insurance…. and the van didn’t belong to the registered keeper.

  19. The young subsidising the old is a feature of any health system. Even in an entirely private user-pays system the ‘average’ would be the younger you saving up to fund the care needs of the future older you.

    A better way of looking at it is that the healthy necessarily care for the sick. Age is just an indicator of health.

    But it kinda fails if the young/healthy are better off not paying.

    In Australia (mixed state/private provision, with tax incentives) there’s a loading system to encourage people to get insurance before they are 30. If they don’t then their premiums are increased if/when they do take a policy.

  20. “Bit like here where young drivers pay through the nose for car insurance to subsidise the older drivers?”
    “My first accident was 5 weeks after buying the car – a car overtaking on a hill suddenly coming towards me on my side of a road and no way to avoid them.My 2nd accident was several years later when a 15 year old reversed a van down the street and slammed into several cars, requiring a lot of repair to the car I had at the time.”

    Slight inconsistency here?

    The young (or at least the newly passed) are far more likely to have accidents than the old, hence why premiums drop with age and experience (and record of claim history).

  21. It might have been Tim a couple of years ago pointing out the flaws in using an insurance system (protecting against an unknown future, eg hit by a bus, catch smallpox) as a savings scheme (saving for a known future, pregnancy, childbirth, getting old, buying contraception via insurance?!?!?!?)

  22. Yes, the difference between insurance and assurance.

    Insurance against being hit by a bus is sensible. Assurance against old age is sensible. But insurance for things better handled by assurance ain’t a good idea at all.

  23. Jim – the young pay over the odds in order to cover others.
    I was a safe driver, of all the car accidents I had just one was my fault – and I blacked out at the wheel before driving off the road. Yet initially I was asked to pay £1700 insurance for a £1300 car. I had before I was banned just 1 accident per 45,000 miles.

  24. I seem to have read that the reason some want to ‘repeal’ before ‘replace’, is that repeal is easier to achieve procedurally than replace, which is a nightmare. Makes sense to me. I assume that those poor that do now have insurance will keep it until it expires.

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