Four is more than two

Last spring, I had some fun smacking around the reactionary ‘argument’ that Obamacare was creating a two tier health system by the simple observation that pre-PPACA, the US had effectively a four tier system, and post-PPACA, we are moving to a three tier system.

We had a four tier system with some caveats and carve-outs in 2009. We are moving towards a three tier system with some caveats and carve-outs under Obamacare.

In 2009 and 2014, the first tier was the tier for the rich and very well insured. Senator Ted Cruz’s $40,000/year family policy that his wife is the primary contract holder for is an example of this tier….

The second tier of 2009 coverage was solid employer provided group insurance and solid individual coverage. It was possible to have solid individual coverage, you just had to be lucky…

The third tier in 2009 was government insurance provided through a variety of programs. The big programs are Medicare, Medicaid, CHIP and the VA….

The fourth tier in 2009 was the “You’re on your own” tier. This was for people who either had no insurance or had insurance that was so skimpy it could not protect people from financial ruin from a moderate size medical event much less a major medical problem.

The fourth tier is being phased out in half the states…

This complaint is back from Forbes — the US medical system will be a two tier system:

Get ready for two different health care systems. In one, patients will be able to schedule a doctor’s appointment in one or two days. In the other, patients will wait weeks or even months – with access problems similar to those in Canada. Patients who get health insurance in the new (Obamacare) exchanges will be in the lower tier. In fact, they may have even greater access problems than patients on Medicaid.

Again,bullshit, going to a two tier system would be a significant improvmeent over PPACA.  Seeing that the author of this piece advocates for free market solutions to healthcare, I would have thought that an intellectually honest indiviual would acknowledge that the people who can pay more for a given service tend to get better service than those who can pay less, and those who can’t meet the market price are SOL.  That would be an intellectually honest if morally depraved argument.  However, the tell is the complaint that people on Exchanges could have it worse than the non-deserving poor on expanded Medicaid.

John C. Goodman, for neglecting to acknowledge that the US explicitly rations medical service by price and PPACA merely reduces but does not eliminate that rationing mechanism by price, AND dogwhistling on both race and class grounds (as those are extremely hard to disentangle in the US), wins asshole of the week.


16 replies
  1. 1
    SRW1 says:

    Still early in the week, but dude is definitely on the shortlist.

  2. 2
    Belafon says:

    If the free market does it, it’s automatically a perfectly fair and valid system, fair in this case meaning that those who can afford it have access to it.

    The government interfering with that outcome is tyranny.

  3. 3
    satby says:

    All part of the New American ethos: to be poor is to be scum, and people’s bad choices in life mean they deserve to be poor. No acknowledgement that luck of circumstances or birth have anything to do with success; and the insistence that the better off DESERVE all the benefits of their status, even if it costs some less deserving poor to suffer. Any attempt to level the field is an assault on the status of the privileged, no matter how little it would actually affect them.

  4. 4
    The Other Chuck says:

    Careful now, that kind of advanced math is the sort of ivory-tower elitism we on the left can’t afford to be associated with.

  5. 5
    Omnes Omnibus says:

    :: counts on fingers :: Yep, four is more than two.

  6. 6
    Xantar says:

    I always wonder about those people who complain about long wait times when we have universal health care. Do they not recognize that if you don’t have health insurance, your wait time to see a doctor is “never in this lifetime?

  7. 7
    pseudonymous in nc says:

    patients will wait weeks or even months – with access problems similar to those in Canada

    As opposed to access problems familiar to those in America, where your waiting time is infinitely long.

    But even that’s bullshit: the Commonwealth Fund’s data shows that waiting weeks/months for an appointment is more common in the US than lots of countries, not least because primary care has more demand than supply.

  8. 8
    300baud says:

    One of the very best things about the web is how it lets actual experts talk to the public directly about the stuff they know without having to worry about the filtering caused editors and advertisers and all that jazz. I love these posts.

  9. 9
    NorthLeft12 says:

    As a Canadian I am a little sick and tired of American one percenters pointing at our system and snickering as if it would be so disastrous for the US to have a single payer system because you have to wait a few months for elective surgery. Boo freaking hoo!
    I can see a Doctor, even my Doctor, within a few days if it is really important. Specialists take a little longer and I might have to travel about an hour, but again, these are not life threatening situations.

    The Canadian woman who the Republicans gleefully used as a poster child for their attack on single payer [SOCIALIST!!] health care, was not in any life threatening danger, but was unwilling to wait her turn for her low priority surgery. She paid through the nose to have it done in the states, which I have no problem with. Waste of money in my eyes, but it is her money and I am sure she will go to her grave claiming her life was saved by that action. Bully for her.

  10. 10
    mellowjohn says:

    “An intellectually honest individual” writing for Forbes?
    you’re joking, right?

  11. 11
    RSA says:

    I followed the Forbes guy’s pointers to sources, a center-right think tank and a medical group survey. The latter report has in its overview, “Almost 80% of survey respondents reported their practice is participating with new health insurance products sold…” based on responses from “700 medical groups in which more than 40,000 physicians practice nationwide.”

    The think tank multiplies the 23.5% who aren’t participating by the number of physicians in the U.S. to produce a big scary number.

    What I found interesting in the survey was the reasons listed for physicians participating:

    To remain competitive in our local market: 57.6%
    Opportunity to replace current charity care as our uninsured patients obtain coverage: 39%
    Opportunity to provide care to an underserved patient population: 35.4%
    Inability to select patients based on their insurance (ex. as a result of hospital affiliation): 22.8%
    Favorable reimbursement rates offer a good financial opportunity for our practice: 14%

    Those first two lines suggest to me that ACA is working for economic reasons, and I’m pretty happy to see the third line.

  12. 12


    Opportunity to replace current charity care as our uninsured patients obtain coverage: 39%

    This is a huge win. The only people who might even classify as losing are the charities that will lose their function now that their charity work is no longer necessary.

  13. 13
    rikyrah says:

    you keep on pulling up crap from azzholes at Forbes who had absolutely no problems with poor people dying from being without health insurance. no shock in the least.

  14. 14
    Mnemosyne says:

    @pseudonymous in nc:

    I also wonder why they’ve never heard of patients with insurance right here in the US of A who have to wait weeks or months to see a doctor because their doctor is booked up. What the hell bubble are they living in where they can see a doctor as soon as they want to, anytime they want?

  15. 15
    StringOnAStick says:

    @Mnemosyne: Exactly. I’ve waited weeks to over a month to see a specialist, and we have great employer sponsored insurance.
    My friends on Canada have never had any of the horror stories the US press loves to harp on, and I’ve been sure to point that out when people say Canadian-style would be so bad. One friend there is a radiation oncologist, who gets paid well and also gets 3 month sabbaticals every few years. Docs here could never take that kind of time off from their practice.

  16. 16
    reality-based says:


    hear, hear. I have a 17 year old nephew. First diagnosed with Chlamydia – which he didn’t have. Then with Epididmytis. Took the doxycyclene. Epidmytis did not go away. With a mass on his testicle. Great health insurance. In Fargo, which is kind of a regional hub for specialists. The soonest my frantic sister can get him in to see a Urologist? 20 days from now. Jeebus sweet christ, how could it get worse?

    You think a brilliant 17 yr old can’t google “mass on testicle” and worry himself sick? As well as his family.

    I think my sister should coach him on how to fake a lot of pain, get them to an ER – strategically planning this for, say, a Tuesday afternoon, at 3 – just so they can get a damn urology consult.

    what – sent to moderation? is it the “t” word?

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