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The PPACA Didn’t “Entrench” the Health Insurance Industry

[ 236 ] December 3, 2012 |

The latest health care thread involves several people making an assumption that’s worth debunking.   Feeble heighten-the-contradictions arguments against the PPACA generally involve claims that the PPACA made “real reform” less likely because it entrenched the health insurance industry.   The obvious problem with this argument is that the PPACA did no such thing.   The health insurance industry is profitable, and as long as it is allowed to cherry-pick customers and has no obligation to use any particular percentage of premium revenues — both of which were true under the status quo ante — it was going to continue to be.   The idea that the health insurance industry would wither away had the federal government just did nothing is sheer fantasy.    And you know who didn’t think that the PPACA was a good deal for the health insurance industry?  The health insurance industry.   Because the insurers expressed some initial tepid support for reform in the abstract, there is an ongoing perception among many people that the Obama administration cut a deal with the health insurance industry.   But, as both Remedy and Reaction and Obama’s Deal clearly report, there was do such deal.  The administration did cut deals with the pharmaceutical industry and with practitioners, but not with the health insurance industry.   And as a result, the industry spent immense amounts of money (as JfL points out, 40% of the Chamber of Commerce’s budget!) trying to kill the PPACA.    Ultimately, the insurers withdrew their nominal support too, but it doesn’t matter anyway.  I am just amazed to see progressives believe that the stated positions of industry lobbies matter more than where they spend their dollars, which is unimaginable in any context other than finding pretexts to attack Obama.  (Wal-Mart says they’re not anti-union, so I guess we have to take them at their word!)   The health insurance industry certainly doesn’t agree that the PPACA was a good deal for them, and they’re right.   It immediately places substantial restrictions on them,  it doesn’t make single-payer less likely, and Laura points out it makes the hybrid public/private systems (cf. France, Singapore) that are even better than single-payer a little more likely.

As for the related argument that the restrictions on the health insurers won’t matter at all because of “regulatory capture,” this is a faux-sophisticated argument. First of all, it proves too much — by the same logic, we might as well repeal the Clean Air Act and the Civil Rights Act because we can’t insure perfect enforcement, which is silly.   Moreover, the PPACA will much less subject to regulatory capture than many other areas of regulation.   Regulatory capture is most prevalent when 1)legislation established vague goals that have to be put into practice by regulatory agencies, and 2)regulations provide diffuse, indirect benefits to the population as a whole that don’t apply to individuals in particular.    The PPACA provides clear statutory rights to direct benefits.   If insurers refuse to provide insurance based on pre-existing conditions, they’re not going to be able to stay out of court.   This is not to say that a Republican administration couldn’t have done significant damage to the PPACA as it was being implemented, and might make enforcement worse at the margin even after it has.    One of the people involved in this discussion does, in fact, tend to ignore the consequences of Republican appointments to federal agencies and the federal judiciary for after-the-fact implementation in favor of onanistic fantasies about how losing the White House is secretly winning.  (Spoiler: it’s not me!)

Then, let us deal with some of the most misplaced self-flattery in known internets history:

if something makes actual reform more difficult, it may not improve the status quo. By your logic, legislators should never oppose a bill due to a poison pill provision.

You seem to have a very binary mind. The leftists you despise think several moves ahead in the chess game. You are constantly criticizing things you don’t understand.

Right, if you fail to perceive that checkers with most of the pieces missing is really eleventy-million dimensional chess, it’s because you just can’t understand the incredibly complex and sophisticated progressive case against the PPACA. (I also enjoy the non-sequitur about “poison pill” amendments. These amendments work because they make legislation on balance worse than not passing it at all. An amendment that makes legislation less good but not worse than the status quo isn’t a “poison pill”; it’s a compromise. They are irrelevant to situations in which legislation improves the status quo.) Anyway, like any progressive who was alive in 2000, I understand immoral and painfully naive heighten-the-contradictions arguments perfectly well. I make fun of them because they don’t make any sense, and in the case of health care reform the betray a comprehensive unfamiliarity with American political history and American political institutions.

The PPACA is not optimal policy; far from it. Neither was anything passed during the New Deal. But by expanding access to insurance and expanding (and improving) Medicaid, provides very substantial and tangible benefits to many people. This places a very high burden of proof on those who would leave these people to death or suffering for imaginary future gains. To oppose the PPACA on heighten-the-contradictions grounds, you need a very plausible story about how a substantially better health reform bill can pass in the relatively near term. And there could not possibly be less basis for this assumption. As already noted, the idea that the heath insurance industry was facing imminent collapse is dreaming in technicolor. The institutional framework — and trying to pass yourself off as a tough-minded leftist if you don’t understand this is a joke — that protects vested interests and makes major reform legislation immensely difficult will remain in place. The uninsured will remain a relatively powerless constituency, and the interests that oppose single-payer will remain very powerful and need only capture one of many veto points. Politics is about power, not teleology — there’s no natural tendency to move towards ideal policy solutions. And think about the politics for a second. Having seen two Democratic presidencies in a row founder on the shoals of health care reform, can anyone seriously think that the next Democratic president in a similar situation will stake her or his presidency on a more ambitious health care plan? That’s crazy, and would be completely inconsistent with actual American political history. The failure of the PPACA would have rendered federal health care reform a dead letter for generations, and ensured that the next reform attempt wold be substantially more timorous.

To inflict real damage on other people because of an (entirely baseless) belief that it will make a better (and unprecedented) bill harder to pass after we’re all dead may be many things, but it’s not progressive. And if the American political context changes so radically that European-style healthcare is viable, the PPACA won’t stop if from happening.

Comments (236)

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  1. Murc says:

    So what’s the over/under on this thread?

    I’m gonna say 125.

  2. witless chum says:

    The best thing about the PPACA, I think, is that it gets the federal government firmly involved in the health care system. I doubt it’ll make things great, but it does make health care absolutely something that you can complain to your congressman about.

    • Scott Lemieux says:

      Right. I don’t see how substantially extending the reach of the federal government in health care makes future reform less likely.

      • david mizner says:

        Well it has to work — or be viewed as working. If it’s seen as working, it will help grease the skids for further reform. If not, not. If it doesn’t “work” or if it gets blamed for general health care system crappiness, it will have undermined the cause.

        Which wouldn’t negate the benefits of getting people insured but would expose the ACA as an ambiguous undertaking.

        I’m glad in any case, that you’re accepting the notion that whether or not the bill makes further deeper reform more likely is a factor worth considering in assessing the overall bill.

        • Scott Lemieux says:

          Well it has to work — or be viewed as working.

          I’m not sure about that. The Clayton Act and the 1957 Civil Rights Act didn’t work. But labor leaders and LBJ, respectively, who knew they probably wouldn’t work still favored them because having established greater federal authority they thought the response to failures would be “make the bills better,” not “the feds should therefore do nothing.” In both cases, they were vindicated.

          Which isn’t, of course, to deny that “working” would be better in every respect.

          • John says:

            Firstly – while the Clayton Act didn’t particularly do anything active to help unions, I had thought its safe harbor provision did end the process of the federal government using the Sherman Act to bust unions.

            Secondly – wouldn’t it make more sense to cite the support of civil rights advocates in congress like Paul Douglas, and actual civil rights leaders, rather than LBJ? In 1957, it was not at all unreasonable to believe that LBJ supported the Civil Rights Act of that year because it was ineffective.

            • Scott Lemieux says:

              In 1957, it was not at all unreasonable to believe that LBJ supported the Civil Rights Act of that year because it was ineffective.

              In 1957, yes. Since we have the benefit of hindsight, we know LBJ wasn’t deliberately sabotaging civil rights.

              • John says:

                I don’t know that we can have a good sense of what LBJ was thinking in 1957 – Caro’s book, at least, left me feeling a bit hazy about what LBJ was trying to accomplish, and whether he thought at the time that further civil rights legislation would be either necessary or desirable.

                • John says:

                  I’d add that the fact that LBJ later became a very effective advocate of civil rights doesn’t prove that he felt the same way in 1957.

                • Scott Lemieux says:

                  At any rate, what LBJ’s motivations were at the time aren’t very interesting. We certainly know that the CRA of 1957 didn’t forestall the CRA and 1964, and the Clayton Act being gutted by Duplex Printing didn’t forestall Norris-LaGuardia.

      • cpinva says:

        it actually makes it far more likely, as time goes on, eventually leading to gov’t run single-payer. it’s kind of a logical progression of events.

        Right. I don’t see how substantially extending the reach of the federal government in health care makes future reform less likely.

        and i think it will come from the health insurance industry itself, as it watches its obscene profits drop, as the result of the pre-existing illness clause being drop-kicked from their policies. the mandate won’t make up for that, profits wise.

    • STH says:

      I think that’s what the Republicans are really afraid of–how much people are going to like it once all the provisions take effect. They’re afraid of another untouchable Social-Security-like program that makes the Dems look good and them look like the assholes they are.

      I think it’s similar to gay marriage; once you get a foot in the door and get it going in a limited way, and the Commie Apocalypse DOESN’T happen, support rises quickly from there.

      • JKTHs says:

        I think that’s what the Republicans are really afraid of–how much people are going to like it once all the provisions take effect. They’re afraid of another untouchable Social-Security-like program that makes the Dems look good and them look like the assholes they are.

        Of course. But that won’t stop them from saying the next time that (major social policy legislation) is Kenyan Muslim socialism that will take away all our freedomz.

  3. Taylormattd says:

    The sad thing is your explanation, which is clearly and obviously correct to anyone who isn’t deeply stupid or delusional, will not change any of those people’s minds.

    • Murc says:

      I dunno. I used to be a lot more Green Lanterny than I am now. I came around largely due to Scott constantly, constantly beating on this drum and because the people arguing against him didn’t really seem to have arguments based on reality.

      And I wouldn’t call people who disagree with this analysis necessarily stupid or delusional. Many people have come of age in an era of conservative/republican dominance of politics, and observing them from the perspective of an enemy will often lead one to political conclusions that, maybe, aren’t applicable to a party that wants to actually govern rather than to torch the country.

      • Bijan Parsia says:

        I used to be a lot more Green Lanterny than I am now. I came around largely due to Scott constantly, constantly beating on this drum and because the people arguing against him didn’t really seem to have arguments based on reality.

        Plus pointers to the literature. I’ve had a similar path.

        One thing that put this strongly in my head was growing up during Reagan. One constant drumbeat was that Reagan (ye olde Great Communicator) would go on prime time, make a speech, and then congress would bend to the might shift in public opinion his stirring words hath wrought. So much on presidential rhetoric as a critical tool.

        Once that’s imbibed as a ground truth, it makes it easy to hold other presidents culpable for their lack of effective use of this powerful tool. Indeed, since the tool is pretty easy to use (if we’re talking charismatic folks like Clinton or Obama) then the only reason they aren’t using it is their true preferences. And there you go.

      • Captain Splendid says:

        I dunno. I used to be a lot more Green Lanterny than I am now. I came around largely due to Scott constantly, constantly beating on this drum and because the people arguing against him didn’t really seem to have arguments based on reality.

        Same here.

        • Bruce Baugh says:

          Likewise. The practicalities of “What are you going to do to get a vote from Ben Nelson?” and the other crucial votes made me realize that if I couldn’t answer the practicalities, I needed to stop acting so sure there were answers I’d like.

          • burritoboy says:

            That was the precise question that got me – well, technically, at that moment the question was framed around Max Baucus, not Nelson. The response was “Primary Baucus” or “Take his committee chairs away from him”. Which suggestions are so laughable that ended the debate for me right there.

        • SN says:

          Yes, believing in teleology is helpful if the goal is a sound sleep at night.

      • cpinva says:

        to my knowledge, this has never stopped anyone from arguing, about anything before.

        and because the people arguing against him didn’t really seem to have arguments based on reality.

        why should now be any different?

        • It’s like undermining al Qaeda.

          No, you’re never going to change the minds of the True Believers, but you can get the great mass of people in the middle to reject their argument.

          • Vance Maverick says:

            Breaking: the third in command of the leftier-than-thou argumentative brigade has been reported killed in a hail of sarcasm.

      • SN says:

        the Green Lantern is silly argument ignores longer-term forces and treats the present moment as if it is an historical inevitability. The Democrats could have fought for single-payer from 1993-2009, but chose not to. History is not teleology and the current configuration of institutional power is not a force of nature.

        • tonycpsu says:

          So, really, your argument is less Green Lantern and more BULLY PULPIT, except somehow Speaker Pelosi and Leader Reid also had BULLY PULPIT powers that could take down Dubya’s inevitable veto?

          • SN says:

            You are using your green lantern meme to argue that what happened with Obamacare is the one and only historical possibility, which is simply silly and a teleology. Seen in the longer-term context of 1993 to 2009, it is clear the the Democrats didn’t and don’t want single-payer. They made a choice to not fight for it over 15 years. And it isn’t just the bully pulpit. There are these things called political parties, they actually have programs, muster resources, mobilize people. There are these things called unions, they can do the same. There are also these things called social movements and they too can fight for political change. Solely focusing on the people who blame Obama per se, or the few who claim Obamacare was a “bailout” isn’t strictly a straw person but it does conveniently ignore the wider scale and the longer term so as to provide an alibi for doing nothing but mocking the over-earnest firebaggers. Recognizing that the Democrats have chosen not to fight for single-payer points you in a different direction politically than making excuses for why Obamacare was the only possible historical outcome of health care policy reform in the last 15 years.

            • tonycpsu says:

              I get where you’re trying to go with this, but am having trouble understand the sequence of events that occurs after Clinton fell flat on his face trying to get a far less ambitious plan through. He took his case to the American people and was met with a resounding “meh.” Cue the GOP outrage, the”Harry and Louise” ad, etc.

              What sequence of steps would have gotten us anywhere near single payer after that? There was zero appetite for healthcare reform throughout the rest of the Clinton administration, and then eight years of Bush. You think Clinton should have just gone back to the well in his second term? Or do you have some other fantasy scenario where he doesn’t appoint Hillary the chair of his task force, or proposes single payer right out of the chute?

              • Scott Lemieux says:

                I’m always been entertained by people who argue that Democrats are incompetent because they fail to use the brilliant strategy for mobilizing public opinion on health care that worked so well for Bill Clinton. I’m also amused by people who think the United States is governed by initiative, although the idea that it you recognize that multiple veto points make it harder to pass social reform you’re guilty of “teleological” thinking is a new twist.

            • Bijan Parsia says:

              You are using your green lantern meme to argue that what happened with Obamacare is the one and only historical possibility, which is simply silly and a teleology.

              “A teleology”? Interesting. Wrong as well.

              It’s interesting that in order to make your case you go to the longer term context. But why not even longer? If Kennedy had taken the deal way back when, things would be much better now.

              The proper temporal point of analysis for a critique of the decisions made during the ACA battle is much more proximate than 1993. In 2009, the decision of 1993 were set and that’s the set of conditions we must analyse.

  4. Sherm says:

    “The idea that the health insurance industry would wither away had the federal government just did nothing is sheer fantasy.”

    Did people really argue that? Or did they instead argue that a better bill would be possible in the future as more people grew disgusted with the status quo? And don’t get me wrong, I’m glad PPACA passed. I’m just disappointed that it’s the best that we can do.

    • Scott Lemieux says:

      Well, I don’t know how else to interpret claims that the PPACA was a “bailout” of the health insurance industry. When companies aren’t “bailed out” they go out of business.

      If the argument is that “entrenchment” means that people will become less pissed off with the insurance industry, that forecloses arguments that the PPACA won’t work at all.

      • Murc says:

        Well, I don’t know how else to interpret claims that the PPACA was a “bailout” of the health insurance industry.

        … did anyone make this claim?

        I saw a lot of claims that the ACA was a giveaway to the insurance industry. That’s a different ball of wax.

        • Bijan Parsia says:

          A search for “aca as insurance company bailout” yields such hits as this:

          His approach to health care was so “pragmatic” that the ACA became an insurance company bailout whose full benefits can’t be demonstrated until 2014, and which became a target leading to Republican control of the House and a near policy stalemate for the past two years.

          and

          Instead, they just said to everybody, that it was impractical and that the United States couldn’t afford it; but that it would be able to to afford a self-supporting PO bill, and later when that was taken off the table, a deficit neutral insurance bailout like the ACA.

          [tbc]

          • Bijan Parsia says:

            [avoiding moderation]

            and this (entitled, “ObamaCare as Corportists United – A Huge Bailout for Another Failing Industry”):

            Why does Corporatism favor Obamacare? Because Obamacare is nothing more than a huge bailout for another failing industry — the health insurance industry. No health insurer could continue to raise premiums at the rate of two to three times inflation, as they have done for at least a decade. No health insurer could continue to pay 200 million dollar plus bonuses to top executives, as they have done repeatedly. No health insurer could continue to restrict Americans’ access to decent health care, in effect creating slow and silent ‘death panels.’ No health insurer could do those things and survive. But with the Obamacare act now firmly in place, health insurers will see a HUGE multibillion dollar windfall in the form of 40 million or more new health insurance customers whose premiums are paid largely by government subsidies. That is the explanation for the numerous expansions and mergers you have seen in the health care industry in the past couple of years. You will see more of the same, and if you are a stock bettor, you would do well to buy stock in smaller health insurers, because they will be snapped up in a wave of consolidation that dwarfs anything yet seen in this country.

            (Note this person really is arguing “bailout” not “giveaway”.)

            I tentatively conclude that people actually made this claim and without misspeaking.

            • Hogan says:

              Counterpunch, though–that’s getting pretty close to nutpicking.

              • Bijan Parsia says:

                I just took the first few hits that were 1) relevant and 2) weren’t LGM :) The Counterpunch hit was one but also there was this:

                First, before I get into my take on it, let me express my absolute disgust and dislike of the term “Obamacare”. It is a political myth that the ACA (Afordable Care Act) was sponsored by President Obama or even resembles the health care reform the President advocated. The ACA was written by the Heritage Group (an insurance lobby group), proposed to Congress by Senator Max Baucus and then heavily modified, both in Committee and in both Houses of Congress. It bears some cosmetic resemblence to the Health Care reform advocated by President Obama but it is, quite literally, an insurance company bailout.

                and this:

                “Act 48 here in Vermont stands in contrast with the insurance company bailout represented in the ACA,” said Vermont Workers’ Center Director James Haslam. “Healthcare is a public good, and we’re on the road to realizing our human right to healthcare here in Vermont through a grounds-up people’s movement.”

                If you could give me an idea of what would count, I can filter more specifically.

                • Bijan Parsia says:

                  Looking a bit more broadly, we have this:

                  Kinsley, and Alter and others may disagree with this analysis, saying it was impossible to pass Medicare for All in early 2009. But the proof of impossibility isn’t there. We know that the Democrats had the authority to end the filibuster in January of 2009 if they wished. We also know that if the President had wanted Medicare for All, a majority vote, or a vote of 50 Democratic Senators plus Joe Biden would very likely have given the President what he wished in the Spring of 2009, before there was ever a tea party to contend with, and when the Democrats in Congress were very much enamored of him. There then would have been no tea party and no bailout of the insurance companies, and likely no Democratic defeat in the elections of 2010 at all.

                  Again, not really filtering for significance of author.

                • Hogan says:

                  I was teasing, mostly. There’s a spectrum from roughly “Health insurers love ACA so much they want to take it behind the middle school and get it pregnant” to “Obama intentionally designed the ACA to save the insurers from the doom they would surely have faced the moment my blog succeeded in waking up the sheeple, which would have been any day now if I weren’t being policed by those meddling LGMers.” The differences are probably less interesting than the similarities.

              • spencer says:

                Didn’t they recently publish something about how the whole Khmer Rouge regime thing never actually happened, and if it did it was okay because everybody loved it anyway?

                I guess what I’m saying is, fuck Counterpunch.

      • Sherm says:

        I suspect that those people meant to say “boon” rather than bailout.

        • Scott Lemieux says:

          Well, at any rate, if the health insurance industry wasn’t declining, then I’m not sure how you can make an argument that doing nothing would be better.

          • bobbyp says:

            I recall the argument being along the lines that the insurance industry would benefit because young healthy folk are now required to be customers-you know, customers who don’t really need the product yet.

            What hurts them is the requirement to cover pre-existing conditions, eliminate caps, and pay out 80% (I forget the exact #) of their revenues for claims – which I suspect is a biggie that is not mentioned very much.

            The quantum leap to finally support the Act vs. asserting “doing nothing would be better” is one I made after a good deal of reading the back and forth both here and FDL.

            Onward.

        • I suspect that those people meant to say “boon” rather than bailout.

          I suspect that they seized on “bailout” as a powerful-sounding word to dress up a crappy argument, and didn’t worry too much about the actual definition.

          You see the same thing with “unconstitutional,” “war crimes,” and “international law.”

          • Bijan Parsia says:

            Bankers, insurance dudes…all the same.

            “Bailouts” were hot on people’s minds.

            Also, a giveaway is bad, but there’s the implication that you could do fine without it. “Bailout” implies that you suck AND we’re giving you money. That’s clearly nastier.

    • Richard says:

      “Or did they instead argue that a better bill would be possible in the future as more people grew disgusted with the status quo?”

      I think this is a good summary of some of the arguments – like from Firedog Lake – on the left. (And I think the “bailout” language doesn’t accurately describe the arguments on the left). The problem is that we have history to prove them wrong. Bill and Hillary proposed a health care bill in Bill’s first term. Never got out of committee. We then had nearly fifteen years for people to get disgusted with the status quo and support a bill much better than the Clinton plan. Didn’t happen. PPACA just barely passed but without majority popular support (and still lacks great support among the voters). What reason is there to possibly expect that all we have to do is have a more years of a bad system and the people will magically change their mind and support a system proposed by the left?

      • Sherm says:

        ” What reason is there to possibly expect that all we have to do is have a more years of a bad system and the people will magically change their mind and support a system proposed by the left?”

        None. Our best chance to remove the insurance industry from the system was with a robust public option, and that is precisely why the republicans and the DINOs were never going to let the public option be included.

        • Hogan says:

          I would be surprised if we don’t see public options showing up on some of the state exchanges, even if they’re not mandated.

        • John says:

          I thought the point was to help people get decent health insurance, not to “remove the insurance industry from the system.”

          • Cody says:

            Well, obviously a lot of us think these are the same goal.

            It always seemed odd to me you have a bunch of people doing a job where the monetary incentive (the only one they care about) is not in your best interest.

            • STH says:

              Exactly. Health insurance as a for-profit industry makes zero sense for the health of those covered by insurance. The way they make their money is by finding creative ways to not pay for health care.

              • Richard says:

                You can say the same thing about any insurance but its just not so. In the short run, a company loses money when it pays out claims. But rather than finding creative ways not to pay for individual health care claims, insurance companies make more money by getting as many customers as possible and one way of doing that is by providing a decent product at a decent price. Under capitalism, there is always going to be some tension between a company making money by serving its customers and making money by screwing its customers. Thats why, especially in the health care field, we need good regulations but it is not necessarily the case that a for profit insurance corporation will not do a good job.

                Up until a few months ago when I turned 65, my health insurance coverage has always been private for profit insurance provided through my employment or my wife’s employment. I’ve always been satisfied with the coverage and service and never once got screwed. Of course, I’m been fortunate to have always been employed so that pre-existing condition coverage has never been a factor. There was a glaring need to fix pre-existing coverage restrictions for people who lose their jobs or are self-employed and, of course, a need to get coverage for the uninsured. But I dont believe there is an inherent evil in private health care insurance.

                • Sherm says:

                  Richard, you’re ignoring that employers routinely switch carriers simply to save a buck or two irrespective of customer service. Providing good service to the insureds and investing in their long term health by paying for testing and care needed to avoid future expenses take a back seat to lowering costs at the expense of the insureds.

                • Richard says:

                  Sometimes yes and sometimes no. I’ve been on the management committee at one of the law firms I’ve worked at and was one of the decision makers regarding choice of insurance companies. Price was a factor but so was service. We didn’t just take the lowest cost provider.

                  Now, of course, there are undoubtedly companies that make the carrier decision based on price alone without regard to service but that is not the universal way of doing things. One way of attracting good employees is to have a good health plan with a good insurer.
                  Moreover, under Obamacare, there are minimum health coverages which all companies must offer, through employers, to employees.

                  I think that single payer insurance would be the best solution but its not happening in my lifetime and I dont believe that private health insurance necessarily leads to terrible health care which is the argument that Cody is making.

                • Sherm says:

                  Well, you’ll be getting single payer for the rest of your lifetime.

                • STH says:

                  Sherm’s right–what insurance company your employer chooses is based on price. And since costs go up so much every year, many businesses switch insurance companies every single year. Are you really suggesting that any company anywhere asks its employees how the customer service was with their insurance company before they switch?

                  Here’s some typical insurance company behavior for you: my state passed a law that required insurance on prescriptions to cover non-generics as well as generics (FYI, my asthma inhaler has no generic equivalent and cost me $118 the last time I had to pay full price for it a few years ago). My insurance company responded by cancelling coverage of ALL prescriptions so they wouldn’t have to comply (my monthly rate stayed the same, though my coverage had been cut). Oh, and I just got the notice telling me that my rate will go up 23% starting in January.

                  The goal of maximizing profit is fundamentally incompatible with the goal of ensuring good health care.

                • Richard says:

                  “Are you really suggesting that any company anywhere asks its employees how the customer service was with their insurance company before they switch?”

                  Yes. That was done with my previous law firm and also with my current law firm (although I’m not on the management committee here). I’m not saying that this is the norm but it certainly is not uncommon (for one reason, management is under the same health care plan as the one it chooses for employees).

                • Malaclypse says:

                  And since costs go up so much every year, many businesses switch insurance companies every single year.

                  That’s fairly rare, as there are overhead costs to switching.

                  Are you really suggesting that any company anywhere asks its employees how the customer service was with their insurance company before they switch?

                  Well, where I work, employees sit on a benefits committee. And the owners get the same insurance we do.

                • Richard says:

                  “Well, you’ll be getting single payer for the rest of your lifetime.”

                  Not quite true. I’m fortunate to have Medicare as a primary insurer but also have a private insurance company as a secondary carrier so I will still be dealing with private insurance. This, of course, is not uncommon.

      • brewmn says:

        The problem no one on the FDL left wants to acknowledge is that 80-85% of Americans have health insurance and, while they may find it a bit expensive, they are happy to have it. The problem with health in America is that we simultaneously pay waaaay more for the health insurance we have than other developed countries, so much more so that the cost will become unsustainable from a budget perspective, and in spite of that cost still have huge numbers on uninsured people.

        And while these are serious problems, the pain won’t be felt by a large majority of Americans until a decade or three into the future. It’s very hard to mobilize public opinion in those circumstances.

      • Josh G. says:

        One reason why momentum for health reform stalled after the Clinton plan’s failure was that the insurance industry actually did do something to restrain costs: HMOs. During the mid to late 1990s, HMOs did a great deal to keep the health care industry from eating the rest of the economy. Unfortunately, they proved so unpopular that they had to be abandoned. Partially this is because they really did involve rationing, and this leads to a lot of pushback, especially if there is the perception that the rationing is being done for private profit, or that the more affluent get to opt out. Only a single-payer system can do rationing with any kind of legitimacy (and even then, it’s still hard).

      • Bijan Parsia says:

        (And I think the “bailout” language doesn’t accurately describe the arguments on the left).

        Not all, for sure. But there are some who made the bailout argument explicitly.

        If you agree that health care costs were long term unsustainable, and you agree that the collapse of heath care due to costs would result in a USA NHS, then anything that fixes health care while preserving the insurance companies is a bail out. Or something!

      • SN says:

        The Democrats did not fight for “Medicare for all” in any substantive way from 1993 to 2009. Scott’s Green Lantern meme falls apart once you look at the issue from 1993-2009. Not supporting single-payer was a political choice of the Democrats, not some innate feature of the constitution or two-party system.

        • tonycpsu says:

          If only Bill Clinton had fought harder, the “Contract with America” GOP would have surely rolled over for him.

          Also too, since you’re including 2001-2009 in your scenario, I guess Congressional Democrats just didn’t work hard enough to establish a veto-proof majority for single payer in Congress.

    • Lee says:

      I’ve seen both arguments. Some people thought that the best solution was to let the health insuarance issue reach crisis level and let it die a slow, natural death. Others thought that if the ACA went done in defeat than a better bill would pass latter. Both arguments are laughable. Every failed attempt at universal healthcare always led to a less ambitious attempt latter. There is no evidence of the health insurance companies dying.

  5. scott says:

    I’m really not interested in the tit-for-tat that seems to consume this site lately, or in whether or not you should oppose HCR to heighten the contradictions or not. I just think that the US paying per capita twice what every other industrialized country pays for health care, for equal or worse results, is A Bad Thing. If the HCR just passed means that health care becomes significantly more affordable and helps solve that problem, making real differences at the bare margins where millions of people live, then great, it worked. If not, it didn’t. One of the reasons I’ll remain skeptical until shown otherwise is that the performance of our so profitable health care industry is pretty bad in delivering affordable health care, and our colleagues in Europe and Japan have solved that problem by making the industry their servant in one way or another. Whether the “softer” version of reform passed here will work as well as more direct reforms that have a prove track record of success is something that reasonable people can differ about. The jury is out.

    • djw says:

      I just think that the US paying per capita twice what every other industrialized country pays for health care, for equal or worse results, is A Bad Thing.

      Indeed. Do you really think anyone here would disagree?

      If the HCR just passed means that health care becomes significantly more affordable and helps solve that problem, making real differences at the bare margins where millions of people live, then great, it worked. If not, it didn’t.

      Just to be clear: if the PPACA were to provide coverage for ~30 million people, vastly improving health outcomes and saving many tens of thousands of lives a year, but not move the lever on health care costs one way or another, you’d consider it a failure and a mistake?

    • Scott Lemieux says:

      I just think that the US paying per capita twice what every other industrialized country pays for health care, for equal or worse results, is A Bad Thing.

      Agreed. How not doing anything at all to address until Congress can pass the Magic Ponies Act of 3025 makes things better is unclear.

    • Murc says:

      I’m really not interested in the tit-for-tat that seems to consume this site lately, or in whether or not you should oppose HCR to heighten the contradictions or not.

      This is another way of saying that you aren’t interested in effective political strategy, other scott.

      I can’t speak for upper-case Scott, but I kind of feel like a large part of why he spends so much time talking about this issue is because as long as Green Lanternism and unproductive heighten-the-contradictions thinking (as opposed to productive thinking in that vein; I do personally believe heightening the contradictions is sometimes appropriate) persists in wide swathes of the left, those swathes will have a tendency to adopt political tactics that don’t work.

      Now, I would prefer the left to do things that DO work. Which sort of means that you have to make the case for your preferred framework of thinking, constantly, over and over, until you win the argument.

      I just think that the US paying per capita twice what every other industrialized country pays for health care, for equal or worse results, is A Bad Thing.

      I don’t think anyone who comments here both regularly and seriously thinks any different.

      Maybe Nieporent.

      • Chatham says:

        “Now, I would prefer the left to do things that DO work. Which sort of means that you have to make the case for your preferred framework of thinking, constantly, over and over, until you win the argument.”

        Have we seen any evidence from the blogosphere that that actually leads to things that do work? It seems to mostly be theoretical conversations by people that aren’t doing much about what others should do.

        • Bruce Baugh says:

          Well, in this very comment thread are people like me talking about how our views changed in the course of the debate.

          • Chatham says:

            Which is great, but what did that lead to? Did it lead you to volunteer somewhere, start a campaign, etc.? What happened that brought it out of the theoretical conversation stage?

            • Bijan Parsia says:

              I switched my party affiliation to democrat (since 2000).

              I donate money to Democratic campaigns. I don’t donate to the Greens anymore.

              Small bits, I know.

              • Chatham says:

                Small, but not unimportant. Voting in Dem (or, hell, Republican) primaries is an important start, even if it’s only a start. Primary participation here is something pathetic like 17%.

                What was it that made you change your party affiliation?

                • Bijan Parsia says:

                  The horroshow of Bush, primarily.

                  I switched to independent sometime in the 90s, I’m pretty sure. I was fed up with Clinton and triangulation, etc. plus this weird civics ethos that was floating around that you should vote the person not the party and exercise your judgment, etc. My mom was sorta that way, partly to explain voting for Heitz and Spector, I think.

                  Toward the end of the 90s I was getting madder and madder at both parties. I flirted with the Greens and Nader in the 2000 election (e.g., donating some money, but ultimately voting Gore). But then the appallingness of the Republicans made me want to signal I was against them in every possible way, so I switched back.

                • Chatham says:

                  Interesting. It doesn’t quite show blog discussion precipitating action, but interesting nonetheless.

                  For what it’s worth, I’ve come to see the general election as mostly defensive. It’s taken me a while to do so, because of the way many hyperfocus on the general. But enough experience eventually lead me to believe that it was going to inherently be about voting for the lesser of two evils, and that more progressive change was possible, but needed to be done through a different venue.

                • Bijan Parsia says:

                  Yeah, sorry. I was blogging then (and very pro-third party) but the change wasn’t prompted by being convinced by another blog.

                  OTOH, blogs like LGM certainly make me more likely to donate to the party. At least, I think so. I came pretty close to slipping into bad habits over the first 2 years of Obama’s term. I’d like to think that the success itself in passing the ACA would have kept me sane, but I don’t know.

    • UserGoogol says:

      The difference between PPACA and “making the industry our servant” seems like a difference of degree rather than of kind. Plenty of countries have systems where highly regulated privately run health insurance companies provide health insurance (with some government backups), the difference is that PPACA is mild in comparison. I do think this will mean that PPACA won’t get results as good as they do, but it does seem to imply that we aren’t exactly moving into uncharted territory either.

      • Cody says:

        This is certainly true. But if you ask a Republican anything short of total free market healthcare is socialism!

        Which is obviously silly. We don’t even have that now.

      • IM says:

        The ACA system can work, Switzerland for example has a system of mandatory insurance with private insurers that are highly regulated and get subsidies.

        But ACA is much weaker then that system in many aspects.

    • Whether the “softer” version of reform passed here will work as well as more direct reforms that have a prove track record of success is something that reasonable people can differ about.

      I don’t think any of the reasonable, or even unreasonable, people here would differ with you: a rational, single-payer system would do a much better job than the “softer,” regulation-based strategy behind the PPACA.

      The thing is, we were never in a position where that was the choice. The choice was between a PPACA-style reform, and no reform.

  6. Hob says:

    Presumably, “And you know you didn’t think…” should be “And you know who didn’t think…”

    • spencer says:

      There were a lot of typos in the original version of the post. I suspect Scott was on a roll when he was writing it. You just learn to read around them when that happens.

  7. Chatham says:

    Well, it does mean that Vermont and possibly California if they pass it will have to wait until 2017 to start single-payer. It also may mean that less states feel pressure to go that route. On the other hand, states would benefit from federal funds, and there’s been some effort to move waivers up to 2014.

    • John says:

      Because lots of states were going to single payer before this?

      • Chatham says:

        Read what I wrote?

        “Well, it does mean that Vermont and possibly California if they pass it will have to wait until 2017 to start single-payer.”

        Vermont has already passed single-payer legislation, and it’s possible that California will as well, especially given the current makeup of the state government.

  8. Steve says:

    This really points the way forward on climate change, too. You want to stop oil from being extracted and burned? Pay oil companies as much money as you can muster to shut up and go away.

    • Murc says:

      Er… wha?

      That… isn’t similar at all to how the ACA is intended to work. Like, at all. In fact a big part of it is forcing insurance companies to take LESS money.

  9. bradP says:

    Regulatory capture is most prevalent when 1)legislation established vague goals that have to be put into practice by regulatory agencies, and 2)regulations provide diffuse, indirect benefits to the population as a whole that don’t apply to individuals in particular. The PPACA provides clear statutory rights to direct benefits. If insurers refuse to provide insurance based on pre-existing conditions, they’re not going to be able to stay out of court. This is not to say that a Republican administration couldn’t have done significant damage to the PPACA as it was being implemented, and might make enforcement worse at the margin even after it has. One of the people involved in this discussion does, in fact, tend to ignore the consequences of Republican appointments to federal agencies and onanistic fantasies about how losing the White House is secretly winning.

    To start with, I’m not really getting the second condition you list here.

    Now, these:

    Medical Loss Ratio Cap w/Rebate
    Minimum Essential Coverage Level
    Size and Scope of the Mandate Tax Penalty

    are enormous administrative levers that have direct control over the rents health insurance industries are able to extract. These levers will be handled by administrators that are almost universally industry insiders. These levers control 1/5th of the economy (and growing rapidly).

    But I’m sure we will have democrats appointing saintly supermen to regulatory posts in perpetutuity, so no reason to be alarmed.

    • tonycpsu says:

      The medical loss ratio isn’t a lever, it’s a matter of dividing medical payouts by total revenues. Any accounting tricks used to hide the ball are going to be audited by career civil servant types, not by industry insiders.

      • bradP says:

        The medical loss ratio isn’t a lever, it’s a matter of dividing medical payouts by total revenues. Any accounting tricks used to hide the ball are going to be audited by career civil servant types, not by industry insiders.

        I’m talking about the caps that are set by the HHS according to the nature and clientele of the particular insurance company.

        • tonycpsu says:

          OK, but, as others have alluded to, this is akin to saying the EPA’s regulations on automobiles are not worth having because automakers were able to skirt minimums by classifying SUVs as trucks. At some point, you accept that the corporations are going to game the system, but having a system is better than not having one to game.

      • Malaclypse says:

        Any accounting tricks used to hide the ball are going to be audited by career civil servant types, not by industry insiders.

        The grunt work on audits is done by entry-level accountants with less than three years’ experience.

        Long ago, I believed that charter schools were a good idea, and worked for a company that managed multiple schools. Now, meals programs get their own P&L, and for boring reasons, always always always lose money. Except one year, one school made a non-trivial profit. And the auditor wants to know why. Now, the real answer had to be that some AP clerk screwed up, and one school paid the food bills for a different school. This is a horrible cluster-fuck, involving real money. This is gonna get bad, fast. So for some reason, I decide to start off with a joke – “Because in [Name Of School District], federal regulations let the school treat catsup as a vegetable.”

        And the auditor said okay, and closed her book, and that was the end of that.

        That said, the loss ratio looks like a difficult thing to game.

        • bradP says:

          That said, the loss ratio looks like a difficult thing to game.

          Doubt it. It is complex legislation.

          While 80-85% may be fairly clear cut, the accounting rules that determine what can be counted and what can’t and how everything is calculated is certainly not.

          Now the extent of the gaming that may take place is up in the air, since the HHS accepted the NAIC’s recommendations on the matter in full.

          • Malaclypse says:

            Wouldn’t be hard to require that any payments made against the 80-85% be made to a list of approved vendors, with exceptions to be audited.

            How many audits have you done, again? Do you really want to get into another accounting argument?

            • bradP says:

              Wouldn’t be hard to require that any payments made against the 80-85% be made to a list of approved vendors, with exceptions to be audited.

              That doesn’t seem to prevent the system from being gamed.

              • Hogan says:

                Which system are you talking about?

              • Malaclypse says:

                Oh fuck me, just stick with your predetermined ideas then. You just know how easy it is to bullshit financials, engaging in widespread fraud, at both high and low levels, without anybody coming clean to avoid federal-pound-me-in-the-ass-prison, without anybody running year-over-year analytics, or looking at an actual general ledger, because, well, because you have completed a couple of 300 level accounting courses.

                This is accounting, not Vietnam – there are rules, and cheating is both difficult and surprisingly easy to detect.

                • bradP says:

                  For some reason, when you think gaming the system, you think cheating the system.

                  When I say they are going to game the system, I mean they are spent buttloads of money to change the rules of the system.

                  Yes, I suppose it would be hard to get around a requirement that 80-85% on a particular approved vendor list. But most aren’t going to try and cheat with their accountants: they are going to spend millions attempting to control what vendors they can use, what exceptions are available, and what expenditures fall within that 80%.

                  This isn’t about good and evil, this is about the methodical remolding of the system itself.

                  I mean, has all that hate directed at Koch’s due to their mastery of accounting tricks, or their spending of millions and millions to skew the rules in their favor?

                • Malaclypse says:

                  they are going to spend millions

                  Well that will trash their loss ratios

                  attempting to control what vendors they can use,

                  Medical expenditures don’t care which vendor provides them.

                  what exceptions are available,

                  15-20% is available for exceptions. Less is Massachusetts.

                  and what expenditures fall within that 80%.

                  Medical expenses. Payments for services provided to the insured. This is not that hard.

                  Now, I know that as a libertarian, theory tells you all you need to know, but, well, loss ratios are in place. You could see how they actually work. You could remember that checks were actually cut last summer.

                  Or you can be sure you know how they will work.

                • bradP says:

                  Medical expenses. Payments for services provided to the insured. This is not that hard.

                  This is the insurance industry’s recommendations to Sebelius that the HHS accepted fully.

                  It doesn’t look near as simple or black and white as you say.

                  Now, I know that as a libertarian, theory tells you all you need to know, but, well, loss ratios are in place. You could see how they actually work. You could remember that checks were actually cut last summer.

                  Or you can be sure you know how they will work.

                  You say “in theory” as if there wasn’t a blatant trend of government being bought out by monied interest.

                  But I know as a progressive, corporations rule everything about this country except the government plans you support. Those are untouchable.

                • Malaclypse says:

                  It looks like a legal contract, Brad. Have you never seen one before? See how it starts with definitions, so that those are nice and clear?

                  But I know as a progressive, corporations rule everything about this country except the government plans you support.

                  As a progressive, I know there is not one single utopian answer, but just meddling through, and trying to make the world better at the margins. There is something to be said for just muddling through.

                • Scott Lemieux says:

                  As a progressive, I know there is not one single utopian answer, but just meddling through, and trying to make the world better at the margins. There is something to be said for just muddling through.

                  There is even more to be said for using the proper baseline — i.e. comparing the actually existing regulatory framework to the status quo ante rather than the Land of Unicorns and Ice Cream Castles where power doesn’t exist.

                  Of course, if we’re talking about the public option, we’re already in utopia — there’s certainly nothing Republicans could ever do to undermine that!

                • Hogan says:

                  This is the insurance industry’s recommendations to Sebelius that the HHS accepted fully.

                  You don’t know what the NAIC is, do you?

                • bradP says:

                  This is the insurance industry’s recommendations to Sebelius that the HHS accepted fully.

                  You don’t know what the NAIC is, do you?

                  Yeah, its a quasi-public regulatory committee that is filled to the rafters with insurance company lackeys like John Oxendine.

                • Hogan says:

                  It’s filled with state insurance commissioners, yes. What specifically about their recommendation reeks of corruption and insiderism?

          • slightly_peeved says:

            since the HHS accepted the NAIC’s recommendations on the matter in full.

            No they didn’t; NAIC wanted sales commissions to health insurance agents to be included as a medical expense, and HHS refused. See here.

        • Murc says:

          You need to start a blog of weird-ass accounting stories, Mal.

          Seriously. There are a million blogs about, say, waiters, and tech support guys, and other people in the service industry, and lawyers, but I’ve never seen an “I’m an accountant, and these are my stories” blog.

          Which is weird because accountants have the best stories. My mother is married to one and my brother is good friends with another, and you get them to a party and get a couple drinks in them and its nothing but these, awful, terrible, wonderful stories about companies and clients they’ve had trying to do things that run the gamut from “dumb” to “breathtakingly illegal.”

    • Murc says:

      Except that all of those levers are well-defined by statute, and thus subject to legal action in the courts.

      It’s not like the ACA says something like ‘companies shall be required to maintain a reasonable medical loss ratio’ where ‘reasonable’ contains a hole you can drive a truck full of money through. It specified ratios, THEN it specifies the actual accounting that has to be used, and so on and so forth.

      Being worried about regulatory capture is legitimate; look at the SEC. And ‘this is going to be subject to regulatory capture, so let’s nuke it and replace it with something that isn’t’ is a serious argument. But let’s not pretend the guys authoring the ACA were blind to the dangers.

      • Hogan says:

        And ‘this is going to be subject to regulatory capture, so let’s nuke it and replace it with something that isn’t’ is a serious argument.

        Except that, as Scott points out, it’s pretty much an argument to not do anything ever.

        It is a legitimate worry, but it was before ACA too, and regulatory capture of the federal government is harder than regulatory capture of a state government. Which is one reason the insurers fought so hard against the bill.

        • Murc says:

          Except that, as Scott points out, it’s pretty much an argument to not do anything ever.

          Destroying something is doing something.

          Example: suppose there’s a pollutant that the environment can tolerate perfectly well in reasonable, well-regulated amounts that are crafted taking in mind local, national, and global circumstances, but when released in large amounts, fucks things over seriously.

          Depending on circumstances, it might be serious to argue “we’re never going to get a regulatory regime here that works properly; it will always be captured. Let’s just BAN the thing, make it illegal to release ANY.”

      • bradP says:

        Except that all of those levers are well-defined by statute, and thus subject to legal action in the courts.

        First, none of them are set in stone. They can all be changed. The minimum essential benefits and mandate penalty will almost certainly have to be modified over time. The MLR requirements are already carved out and follows recommended by the insurance industry itself.

        • Hogan says:

          First, none of them are set in stone. They can all be changed.

          Which distinguishes PPACA from what, exactly?

          • JKTHs says:

            Uh don’t you know? Once a single payer system is enacted it takes a supermajority of 95 votes in the Senate and 400 in the House to eliminate it.

            • James says:

              And there will never be arguments about funding, nor will any Prime Min President come to power and reduce funding or privatize part of the apparatus.

              In a way, this whole chain of reasoning reminds me of arguing with libertarians a decade ago (often about regulatory capture, come to think on it). You will never have a system that is so perfect that you get to stop arguing over it. Sometimes the austerity people will even be right. Not often, but it can happen. It isn’t like single payer isn’t ultimately a regulatory regime anyway, unless you draft every health care provider in America.

              FWIW, I have a dog in this fight from both sides. I’m married to a physician (an oncologist) and I’ve got a chronic, debilitating health condition. From our point of view, the ultimate system is “VA for everybody” or maybe “Kiaser for everybody”. But both those kinds of systems have their own flaws as well. You can have better, and you can have different, but you can’t have flawless, and you can’t have “okay. Good as it can be. Now we can completely turn our eyes from it and it will run like magic without intervention”

      • bradP says:

        But let’s not pretend the guys authoring the ACA were blind to the dangers.

        It isn’t so much that they are blind, negligent, or even supportive of the dangers, it is that they necessarily value the consequences differently.

        Timothy Geithner is not incompetent or evil, he’s a banker. The administrators of this won’t be overwhelmingly incompetent or evil, but they will be overwhelmingly associated with the health insurance industry.

        • tonycpsu says:

          We go to war with the regulators we have, not the regulators we might want. At some point, you’re just trolling everyone here unless you have some other steps we could have taken to get to a better outcome than PPACA as it stands today.

        • Scott Lemieux says:

          You have made a plausible case that the regulatory process will be more influenced than powerful interests than one would prefer. You do not have a remotely plausible case that the situation would be better if we just didn’t have the regulations at all. Since the latter question is the one that’s actually relevant, this is a serious problem.

          It’s the classic libertarian bait-and-switch: sometimes corporate interests will distort the regulatory process, so let’s just eliminate the regulations entirely!

          • bradP says:

            Ignoring the shot on libertarians that I opened up for you, that isn’t particularly fair to your opponents on this issue.

            Its not even particularly fair to me since I support a public option (and that is what the insurance industry really opposed and got shot down).

            • tonycpsu says:

              In what way is it not fair, and how does your support for the public option make your logic any more valid?

            • Murc says:

              that isn’t particularly fair to your opponents on this issue.

              Well, let’s be fair, then.

              What specific politically possible fix do you advocate aside from a regulatory regime?

              Nobody here likes how regulatory regimes get captures, but you have to make the case that doing nothing is better than having a flawed regulatory body, or that there’s a superior method than establishing regulations that could have been included in the ACA.

              • bradP says:

                Yes, I am aware that an incredibly unpopular mandate and tax penalty was passable but a fairly popular public option wasn’t. At least I am aware that the serious people here are sure of that. I am also aware that the only thing standing in the way of a public option were insurers.

                So really, I guess we have reached the point where the argument has become meaningless:

                I say that the PPACA will entrench insurers to the point that real, lasting reform becomes impossible. You say that the insurers were already so entrenched that anything that might have touched them was impossible.

                • Malaclypse says:

                  You didn’t actually answer Murc’s question.

                • Scott Lemieux says:

                  I say that the PPACA will entrench insurers to the point that real, lasting reform becomes impossible

                  Please to be citing evidence that the insurers were going anywhere absent the PPACA.

                • Murc says:

                  I say that the PPACA will entrench insurers to the point that real, lasting reform becomes impossible.

                  Well, that’s a point of view, I guess, but I don’t think you’ve made a convincing case.

                  I’ll concede that if this were true, it would be a good reason to oppose the ACA, because I am in agreement that eventually private insurers are going to need to be sidelined, if not eliminated, to get us to a method of health care provision that’s sensible.

                  But I don’t see how the ACA made the insurance industry MORE entrenched than what we had before. In fact, if anything, it makes them less entrenched; it guarantees them customers, true, and that would usually serve to entrench an enterprise, but it also chops the amount of profit they can extract from said customers severely and forces them to operate in a manner similar to public utilities.

        • Pseudonym says:

          Timothy Geithner could be called a central banker, perhaps, but he’s a career civil servant and economist with no experience in the private banking industry.

    • Pseudonym says:

      Republicans, who according to some may one day be elected, would in contrast never fuck with a single-payer system if we had that instead. The very idea of the GOP trying to sabotage Medicare is inconceivable!

  10. bradP says:

    Also, I followed this link in this sentence back:

    And as a result, the industry spent immense amounts of money (as JfL points out, 40% of the Chamber of Commerce’s budget!) trying to kill the PPACA.

    And it traces back to a Bloomberg article written all the way back in 2010 that says:

    The insurance lobby, whose members include Minnetonka, Minnesota-based UnitedHealth Group Inc. and Cigna Corp. of Philadelphia, gave the money to the Chamber in 2009 as Democrats increased criticism of the industry, according to a person who requested anonymity because laws don’t require identifying funding sources. The Chamber got the money from the America’s Health Insurance Plans as the industry urged Congress to drop a plan to create a competing government-run insurance plan.

    So, yeah. AHIP donated $86M before Obamacare was passed to try and kill the public option.

    • Hogan says:

      And then what happened?

      The talking points created by the Strategic Communications Advisory Committee of the AHIP were disseminated to the American public by an array of conservative groups (US Chamber of Commerce, Karl Rove’s Crossroads GPS, and the American Action Network) that spent $235 million on ads attacking the PPACA since its passage in March 2010.

  11. Dilan Esper says:

    I am on my mobile and can’t respond in detail. But seeing that this is in the main a response to me, I do want to say that this is an improvement for Scott, in that he may finally realize that the long term matters and that Republicans will sometimes win elections. He is still wrong on the merits though, and I will respond in detail later.

    • Murc says:

      But seeing that this is in the main a response to me

      I seriously doubt that.

      Scott has been known to respond to commenters and peers, frequently and robustly; but when he does, he names names.

      And that notwithstanding, Scott has been shouting about this issue from the rooftops for over four years now, in one form or another.

    • T. Paine says:

      Not holding my breath for it to make any sense.

    • Karate Bearfighter says:

      Any chance you’re going to provide some of the “many examples in history of contradictions being successfully heightened”? ‘Cause I’m drawing a blank, and I think this is essential to your claim.

    • Scott Lemieux says:

      that Republicans will sometimes win elections

      This may surprise you, but I do understand this. What I do not agree is that it’s a good idea to enable them to win more elections than they would otherwise in exchange for nothing.

    • Joe says:

      “The latest health care thread involves several people making an assumption that’s worth debunking.”

      But, “in the main” only you count. Scott repeatedly is concerned with the long term & knows Rs will sometime win elections. Whenever you go into scorn mode, you become a tad insufferable.

      BTW, again with the Medicaid sucks bit. Medicaid like various programs for the poor have problems.

      Still, it is not better merely than dying & given the realistic alternative was NOTHING, expansion for many more people, including yes in some cases for people who would die otherwise, it was alone significant.

      It would have been nice, especially with the political system in place (and yes, the reality that “Republicans win elections” … as they did in 2010), if we could have had a better health care law. But, I’m unsure how a better one realistically could have passed & the one that did helps lots of people.

    • he may finally realize that the long term matters and that Republicans will sometimes win elections.

      This is exactly the type of pompous twaddleknockery that makes internet douchebags the most annoying, least important human beings on the face of the earth.

      Gee, I wonder why people disagree with me about politics? I know: it’s because I, and I alone, understand that Republicans will win elections/can read the phrase “shall not be infringed”/understand the parts of “illegal”/care about “brown people.”

      If you find yourself writing things like this, the world would be a better place if you stopped discussing politics and took up knitting.

  12. Sly says:

    This places a very high burden of proof on those who would leave these people to death or suffering for imaginary future gains.

    You mean I can’t make someone else the martyr for my optimal policy outcomes?

    Well… that’s just no fun at all.

  13. wengler says:

    This post will almost certainly cause comment to go down the typical paths so I thought I might try to find something now.

    Obama getting re-elected means that Obamacare will be implemented and here to stay. We will most likely see the Republican strategy take a different tack from now on.

    They are almost certainly going to try to push to end Medicare and fold it into the PPACA system.

    Politically they would be smart to do this. Medicare is already under strain that will be much more acute as more and more boomers retire. They would be putting Democrats into the position of choosing between the two signature healthcare programs passed by Democratic presidents in the last 50 years, both of which Republicans would gladly destroy.

    • tonycpsu says:

      I choose Medicare. New minimum age: zero.

      What do I win?

    • JKTHs says:

      Yes I can wait for concern trolling Blue Dogs being like “See, now we don’t need Medicare because we have these totally awesome exchanges” regardless of whether or not they are actually more efficient than Medicare (probably not).

      We already had some minor variant of this among centrists saying that Ryancare and Obamacare are the same thing, completely ignoring the context in which each proposal takes place.

  14. SN says:

    Indubitably Dr. Lemieux the PPACA is the best and only possible healthcare reform that could have been accomplished because of James Madison, primate evolution and the topography of Pangaea.

    Or maybe history isn’t some grand inevitable teleology and the people who run the Democratic party chose to not fight for single-payer from 1993 to 2009 because they are not a center-left party at all but rather a center-right party of FIRE sectors.

    • Scott Lemieux says:

      Yes, if 1993-4 proves anything, it’s that if the president takes his case about health care to the country, its passage is inevitable.

      Also, to state the obvious the Democrats aren’t a “center-right” party in any sense that’s meaningful to American politics.

      • I’d argue that, post the arrival of Third Wayism in Europe, the Democratic Party aren’t center-right in European terms – at least if some basic conception of Keynesian economics is included as a redline for center-leftism (as they should be).

        • +1. The notion that the Democrats are center-right by European standards seems to be based on nothing so much as the fact that European center-right parties have more or less accepted the existence of popular social welfare programs, national healthcare, etc. But that’s merely a matter of political necessity as much as anything else, and in all likelihood, if the U.S. had similar parliamentary governance the GOP would lose their opposition to Medicare and Social Security pretty damn quickly as well, lest they never win another election.

          • Chatham says:

            “But that’s merely a matter of political necessity as much as anything else…”

            But that’s what politics is. It may explain why Democratic politicians would be center-right in the European spectrum for some issues, but it doesn’t negate it.

            • To point out the obvious, “Democratic politicians” and “the Democratic Party” are two very different things. Yes, Ben Nelson would be on the center-right of European politics. The national Democratic Party and their leadership team in Washington would not be.

              • Chatham says:

                Of course, which is why I made the distinction in my post, rather than talking about “Democrats.” And also why I specified some issues. As you noted in your post, the focus tends to be on social welfare issues, not, say, immigration or civil liberties. With that said, I should add that Democratic politicians and individuals in the leadership aren’t monolithic, and neither is “Europe,” which is comprised of many different countries.

                • But this is a pretty meaningless comparison, in so much as center-right Democratic legislators are a by product of America’s unique electoral/governing system. Get rid of the Senate and elect representatives by proportional voting and they’d go away overnight.

                • Chatham says:

                  I’m not sure why you think it makes it meaningless. Just about every politician is shaped by their environment and the system they’re in. I’m sure that if single-payer passed and it was widely popular here (and I imagine it would be), many politicians on the right would start to act very differently.

                • Because you’re comparing apples and oranges in looking at two systems with vastly different rules and complaining about the unique outcomes one leads to through the prism of the other. It’s like complaining that tennis players don’t tackle well enough or something.

                  Also, the Ryan Medicare plan pretty much tears apart your last sentence.

                • Chatham says:

                  “Because you’re comparing apples and oranges in looking at two systems with vastly different rules and complaining about the unique outcomes one leads to through the prism of the other.”

                  No. I’m explaining that the outcomes are what they are. Go back and look at what I wrote; you’ll find that I never complained about this, or said “European politicians are so much better!”

                  “Also, the Ryan Medicare plan pretty much tears apart your last sentence.”

                  Yeah, no. Ryan has to at least pretend to like Medicare. In fact, most Republicans do. How many pretend to like single-payer right now? Do you think more or less will if it ever becomes law and becomes popular?

      • Chatham says:

        “Yes, if 1993-4 proves anything, it’s that if the president takes his case about health care to the country, its passage is inevitable.”

        We don’t live in a binary world. There’s a lot of space between action that makes something inevitable and action that’s pointless.

        • Scott Lemieux says:

          As it happens, bully pulpitin’ is rather closer to the “pointless” end of the spectrum.

          • Chatham says:

            Well, I know that some members of congress whose position on certain issues is based as much on finding a compromise position as anything else. I also know that there were some Democratic activists who were disappointed by what the president said, and ended up not working on the 2010 campaigns. I don’t think influencing either of these groups is meaningless.

            And that’s just talking about what the president could do rhetorically. That’s certainly not the only thing that the Democratic Party could have done.

            • “Well, I know that some members of congress whose position on certain issues is based as much on finding a compromise position as anything else.”

              Perhaps. The problem with this vis a vis the PPACA is that those Democrats wound up being forced to forge a “compromise” with other Democrats, as Republicans checked out completely. So what relevance it has I don’t know.

              • Chatham says:

                Plenty of relevance. If you have to find a compromise with Democrats, and some of them don’t have fixed positions, but rather like to take the middle-ground, where that middle-ground is matters.

                Would it, on its own, have changed the results of what passed? If I had to guess, I would say no. But that doesn’t mean it has no effect on negotiations.

                • Except, based on observed reality, it would appear that a meaningful amount of those pivot point votes actually did have fixed positions on what they were willing to support.

                • Chatham says:

                  At least a few of them didn’t, based upon talks I’ve had with people who’ve worked for them. I don’t think that’s unimportant.

                • Well, since it only took one defender to torpedo the whole thing, it quite clearly is irrelevant what “at least a few of them” thought of the matter.

                • Chatham says:

                  Well…

                  “Would it, on its own, have changed the results of what passed? If I had to guess, I would say no. But that doesn’t mean it has no effect on negotiations.”

                  Eh…if you think anything that wouldn’t guarantee a different outcome for what was passed is irrelevant, that’s fine, I suppose, but I disagree.

                • I do enjoy the ongoing level of hand-waiving matters of degree that’s going on here. But sure, “doesn’t guarantee a different outcome” and “would most likely have no tangible impact whatsoever” are totally the same thing.

                • I should also note that I find it incredibly odd that so-called hard eyed leftists are basically viewing the actions of Lieberman, Bayh, etc. in the best possible, least nefarious light, while would-be corporate sell outs like Scott and I basically assume them to be completely useless fuckwads.

                • Chatham says:

                  I don’t see “would probably not have made much of a difference in the outcome in this particular situation” and irrelevant to be the same thing. For example, I don’t think if the actions from the AARP were different – even substantially so – there would have been a different outcome. I wouldn’t call any action by the AARP irrelevant because of this.

                • Chatham says:

                  “so-called hard eyed leftists”

                  So called by who?

                  ” are basically viewing the actions of Lieberman, Bayh, etc. in the best possible, least nefarious light,”

                  I assume this is a reference to someone else? Because it has absolutely no connection with what I said.

    • Hogan says:

      Because as we know, when they founght for single payer from 1948 to 1968 they totally got it.

    • Murc says:

      Indubitably Dr. Lemieux the PPACA is the best and only possible healthcare reform that could have been accomplished

      I don’t think I’ve ever seen Scott argue this, which is good, because he’d be wrong.

      Of course the Democratic Party could have spent the fifteen years between Clinton crashing and burning doing things much differently than they did, and part of the reason they didn’t do things differently is because there are a lot of people in the Democratic Party who just aren’t that liberal.

      But there are other reasons as well.

      And even those reasons notwithstanding… once we actually got to 2009, we had to deal with, you know, the situation as it was. You got a way we could have gotten a better bill THEN that doesn’t involve ‘do a better job over the previous decades?’

      the people who run the Democratic party chose to not fight for single-payer from 1993 to 2009 because they are not a center-left party at all but rather a center-right party of FIRE sectors.

      In a global context, the Democratic Party is indeed a center-right party that is grossly influenced by the FIRE sector. This is, indeed, damning, and it’s one of the Democrats biggest failures.

      In an American context, they’re center-left.

      • Scott Lemieux says:

        I would like to add that it’s nice that SN has heard about Candide third-hand or whatever, but highbrow literary references are unable to turn straw into gold.

  15. Mike D. says:

    “Or did they instead argue that a better bill would be possible in the future as more people grew disgusted with the status quo?”

    If this was the argument, should we respect it any more than we would the assertion PPACA was a bailout? Explicitly acknowledging things are gonna get crappier, which in real terms means people needlessly dying, going bankrupt or losing large shares of their income, or just being unnecessarily ill, in exchange for the suggested hope that “maybe then we’ll be able to pass Teh Awesomesauce HCR Bill of two-thousand-never,” meanwhile not addressing the distinct possibility that the health care industry as a result of that human backsliding becomes ever more used to its handsome profits and lack of required benefits standards causing their political influence and motivation to exercise it to increase over time (there’s a word for that process; I think it stars with ENTRENCHMENT), while the public gets more and more condition to accept dysfunction and getting exploited in this area.

    Sorry, this is kind of a restatement of the OP. But wow, is “let’s choose not to improve things and instead knowingly let them get worse in the hopes that this will enable a hoped-for Moment of Ideal Policy Enactment to perhaps eventually arise” ever a crappy argument.

    • Mike D. says:

      “…Explicitly acknowledging …[etc. etc.]… in exchange for… [etc. etc.] … while not addressing [etc. etc.] …”

      …seems like an equally dismissible argument as saying that PPACA was a bailout of a failing industry (I meant to say at the end of the first paragraph there).

    • Scott Lemieux says:

      should we respect it any more than we would the assertion PPACA was a bailout?

      No.

    • Sherm says:

      Only to the extent that honest arguments deserve more respect than dishonest ones. But either way, the uninsured suffer while proponents of single payer bide their time waiting for more public support.

  16. Duncan says:

    Actually this was a surprisingly popular theory back in 2009; people asked ‘well why is the act so bad’ and commentators said ‘aha, it’s a cunning trojan horse. There’s too much opposition to a single payer system but this act will simultaneously undermine the existing insurance system and be so unsatisfactory for everyone that everyone will agree that transitioning to a single payer system is the only way’. That was before mass purchase bargaining was stripped from the act, of course, and before the Republicans demonstrated how effective they were at opposing even neoliberal conservative reforms in the 2010 Midterms.

    • Murc says:

      ‘aha, it’s a cunning trojan horse. There’s too much opposition to a single payer system but this act will simultaneously undermine the existing insurance system and be so unsatisfactory for everyone that everyone will agree that transitioning to a single payer system is the only way’

      I didn’t see commentators who were in favor of it arguing the ACA would be so unsatisfactory that eventually people would agree that transitioning that single payer would be the only way. That’s a dumb argument.

      The one I’m familiar with is that the ACA, like Social Security and Medicare before it, would work well enough that it would be improved upon and expanded as the years went by. Which is sort of the exact opposite of what you just said. It’s less ‘trojan horse’ and more ‘foot in the door.’

  17. I’m late to the party, so maybe this has already been said, but I feel like pointing out that the “won’t someone think of the future of single payer!” kvetch is also grossly immoral on the face of it. The only way it makes sense even on its own terms is if you fear that the PPACA framework will generally serve people well and ultimately become popular enough that there’s no public appetite for major overhauls to the broad contours of the bill. Which is to say that people advocating it are basically saying outright that they don’t want to make peoples’ lives better anytime soon if they fear it will impede the possibility of sticking it to corporations at some indeterminate future point.

    • Murc says:

      The only way it makes sense even on its own terms is if you fear that the PPACA framework will generally serve people well and ultimately become popular enough that there’s no public appetite for major overhauls to the broad contours of the bill.

      Err… no.

      I’m firmly in favor of the ACA on its own merits, but the ‘further reforms are made more difficult’ argument doesn’t run that way. The idea isn’t that the ACA will work really well and satisfy people such that they won’t WANT more reforms; the idea is that it will ameliorate just enough of our problems that we exist in a perpetually shitty-but-survivable state when we could be doing better.

      To use an analogy; someone who has cancer will have their life made better if they’re provided with properly managed pain meds. That’s much better than nothing. But what they NEED is chemotherapy and an aggressive treatment regimen. Instituting a regimen of pain meds may in fact be counterproductive in the long term if people will use it as an excuse NOT to provide any further treatment.

      Now, I disagree with this logic based on disputing its first principle, but it does make sense and it isn’t grossly immoral. If I thought for one second the ACA actually did make further reform much more difficult, I might reconsider my support.

      • “the idea is that it will ameliorate just enough of our problems that we exist in a perpetually shitty-but-survivable state when we could be doing better.”

        That basically just restates my point, albeit with a very low bar for what we think will placate public opinion.

        “To use an analogy; someone who has cancer will have their life made better if they’re provided with properly managed pain meds. That’s much better than nothing. But what they NEED is chemotherapy and an aggressive treatment regimen. Instituting a regimen of pain meds may in fact be counterproductive in the long term if people will use it as an excuse NOT to provide any further treatment.”

        I don’t see how this analogy holds. There’s absolutely zero reason to assume outright that the PPACA makes further reforms by future politicians any more or less likely from this vantage point. The problem from a further reform standpoint would have to be that the public at large is generally happy with the existing state of things, at least to the point that they’re fearful of making changes to things. Medicare is a pretty good example: it’s not the most efficient policy right now and needs some sort of cost controls on healthcare costs to remain viable in the long term, but overall it’s very well liked, which makes people extremely wary of making even necessary changes that involve “cutting spending” on it.

        • Murc says:

          Er… you’re right about all those things, but I’m not sure how they’re relevant to this specific discussion.

          You said that the stance of those who think the ACA shouldn’t have been passed because it makes further reform difficult-to-impossible is ‘grossly immoral’ because:

          The only way it makes sense even on its own terms is if you fear that the PPACA framework will generally serve people well and ultimately become popular enough that there’s no public appetite for major overhauls to the broad contours of the bill.

          And I’m saying that that argument isn’t being made by those on the other side of this discussion.

          The analogy I used IS wrong. But it’s only that; wrong. It’s not illogical if you accept the premises it is working from, nor is it grossly immoral, and it is much closer the actual viewpoint of those who don’t believe in the ACA than the views you attributed to them.

  18. Dilan Esper says:

    1. Time will tell regarding whether health insurers got entrenched. But certainly the structure of Obamacare is designed to entrench them, by forcing the American people to patronize them. Note that if I am right about regulatory capture and insurance companies being unable to put patients before profits, the mandate stays in place. That’s important. It also stays in place even if the subsidies are inadequare or get cut or if some states do not expand Medicaid.

    2. You keep mentioning insurance industry lobbying. That is not an argument. It is a whine. The industry likes the status quo, obviously. That doesn’t nean they can’t capture the regulators and continue to deny care under the new law. It may just cost them some money. So they prefer the status quo. Doesn’t mean the new law is any good.

    3. Obamacare is actually perfect for regulatory capture. The states administer the Medicaid and all the insurance rules. Most state insurance commissioners are owned by the insurers. Believe it or not, many of the law’s provisions are already in place in state laws. They are not enforced.

    There are two major things the federal government enforces in Obamacare, and one of them is the mandate. Again, even if insurers continue to drop coverage and states do nothing about it, the mandate still gets enforced.

    4. The expansion of coverage is easily gutted. This is a key difference with FDR. Social Security is an entitlement, which is much harder to cut. Here, it is a tax credit which might not even survive the debt talks, and grants of money to states through Medicaid, which they can decline and which is a deliberately underfunded health program to begin with.

    You b actually still could be right about Obamacare. But the idea that just because this was falsely labeled a national health insurance program nobody on the left can say it is counterproductive is just another attempt to shut down criticisms from people who think past the next election.

  19. Pepe says:

    Walmart really likes the PPACA, which provides neither affordability nor care (insurance isn’t care), and in fact, the brains behind the PPACA think the costs are too high because Americans go to the doctor too often, so to cut costs – less care! But I digress: Walmart Champion of PPACA

    http://www.emptywheel.net/2012/12/05/walmart-takes-advantage-of-health-reform-it-championed/?utm_source=rss&utm_medium=rss&utm_campaign=walmart-takes-advantage-of-health-reform-it-championed

  20. [...] etc.) just end up re-stating the heighten-the-contradictions fallacy — i.e. the ACA was bad because it “entrenched” a private health insurance industry that was, in fact, doing perfectly well before the ACA. The idea that absent the ACA it would be [...]

  21. [...] all things considered, than allowing the default later.” This isn’t the same as the heighten-the-contradictions arguments for defeating the ACA, because this would clearly make things far worse in the short term (no Medicaid expansion, no [...]

  22. [...] now working directly for insurance rentiers, while at least most firebaggers are working for them only indirectly.) The Dean-was-our-savior argument is almost as bad as the Hillary-Clinton-is-the-new-Eugene-Debs [...]

  23. [...] destroying the American health insurance industry, you can ludicrously argue that absent the ACA the health insurance industry would have just dissolved on its own, allowing you to pretend that your preferred strategy of Obama using the bully pulpit to favor single [...]

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