The ACA in 2018 and Obama’s 2007 vision

This is worth at least an quasi-ironic chuckle.  The implementation of the Affordable Care Act in 2018 is closer to some elements of the early 2007 campaign version of Obama’s health care vision than the ACA implementation from 2010-2017 was.

Now let’s go look at the tape, from Polifact 2007:

Obama shot back: “Well, let’s talk about health care right now because the fact of the matter is that I do provide universal health care. The only difference between Sen. Clinton’s health care plan and mine is that she thinks the problem for people without health care is that nobody has mandated — forced — them to get health care.”….

One of the few differences is that Clinton and Edwards include a universal mandate….

Obama’s decision not to include a mandate is a more cautious approach, one Obama says is designed not to penalize people with modest incomes. If premiums don’t drop enough after all the reforms are implemented, people will still be unable to afford insurance.

Obama contended during the 2008 primary that the subsidies would be rich enough that no mandate would be needed. And then the desire to hit a particular CBO score came into play as well as a need to not lose a single Democratic senator dictated that subsidies were going to be a lot weaker than the House wanted.

However with Cost Sharing Reduction (CSR) sabotage leading to Silverloading and Gold gapping, subsidies for individuals who make between 100% Federal Poverty Line (FPL) and 400% FPL ($12,020-$48,080) will have become effectively much richer for people who buy plans that cost less than the benchmark.

This is just an irony if seen from a skewed point of view.






15 replies
  1. 1
    Daddio7 says:

    Even with the subsidy my wife’s market place silver plan would be 40% of her $30,000 income (I am on Medicare). She opted for her company’s ACA compliant (they call it enhanced bronze) plan. With deductibles it will (only) be one third of her income. Everyone is focusing on how to pay for our medical care, why is no one trying to find out why we spend twice as much as other first world countries for our care?

  2. 2
    Another Scott says:

    @Daddio7: Dean Baker at CEPR discusses the high cost of US health care a lot.

    Sorry that it’s so expensive for your family. Too many people are in that situation. :-( The real crime is we know how to fix this problem and it wouldn’t be at all difficult. We just have a Republican Congress that refuses to do so.

    Cheers,
    Scott.

  3. 3
    the Conster, la Citoyenne says:

    @Another Scott:

    Republicans? what’s that? according to our progressive betters, Obama and corporatist Dems sold us out to big Pharma even though they had a SUPERMAJORITY argle bargle.

  4. 4
    Chyron HR says:

    @the Conster, la Citoyenne:

    Mmmmm, big parma.

  5. 5
    tobie says:

    David, I know I missed the post where you explained how Trump’s CSR refusal has actually lowered the cost of some policies for people earning between 100% and 400% of the federal poverty level but I overlooked it. Could you provide a link to the post? Thanks.

  6. 6
    Raoul says:

    @Daddio7:

    is no one trying to find out why we spend twice as much as other first world countries for our care?

    Shhh. We can’t critique capitalism. It’s the best! Even if it means healthcare profiteering.

    My latest high horse is a common, and old, gout drug, colchicine. It costs about 50 to 75 US cents equivalent in Canada and England. But the FDA gave a manufacturer exclusive rights because they did an efficacy test some years back (it was on the market before any such testing was required – many many decades). Surprise, the drug that has been used in some form or other for centuries, works! For that, the manufacturer can charge $9/pill for some period of exclusivity – no generic even though the drug is literally ancient.

    My rheumatologist was visibly pissed off as he talked about this. He used to prescribe it in low doses as a preventative. But with the price spike, it went from $22/mo to $270/mo.

    I know there are bigger cost drivers than this one drug, but it is IMO emblematic of the perverse incentives of rentier capitalism seeking unfair advantage in markets where the buyer has NO price-setting power. Capitalists can make what they dare because we are motivated to not be miserable (or dead too soon!).

    Though that parenthetical bit is also an important cost driver: We spend far more on the last six months of people’s lives here in the US than in other countries. Are our last 6 months better quality of life than theirs? I suspect not, but we have a “I’m insured, throw everything possible at me!” attitude to life extension, not life-worth-living. Yeah, I know — death panels!!

    But good palliative care can be a blessing, if we let it be a balancing act, not a (literal) death-grip gotta stay on this earth every second miracle medicine can make me last. Four or so years ago, I watched my dad slip the bonds gently, DNR on the coffee table in the other room. Hospice nurse just kindly observing quietly in the corner of his bedroom at home, me and his beloved lady friend holding his hands. He made the right choice, IMO.

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  9. 9
    Another Scott says:

    @Raoul:

    We spend far more on the last six months of people’s lives here in the US than in other countries. Are our last 6 months better quality of life than theirs? I suspect not, but we have a “I’m insured, throw everything possible at me!” attitude to life extension, not life-worth-living.

    To be fair, that wasn’t the experience my dad and my best friend from high school had in 2017.

    My dad had uveal melanoma. The prognosis was always grim, but he didn’t know if he was going to live 6 months or 10 years. He survived about 3 years. He was only in hospice for a few weeks – before that he was only in the hospital for chemo and the occasional complication. He was 82.

    My best friend had AML leukemia. He was diagnosed just after Father’s Day 2017 and died in December. He was young enough that he had about a 35% chance of surviving 5+ years. He went through several cycles of chemo and was within a day or so of getting a bone marrow transplant before he had a final relapse. He had been hospitalized for several extended periods during his treatments. He was 56 and died in the ICU in a hospital that had a specialized leukemia wing.

    The last 6 months are expensive because they involve hospitalization – and often intensive care – and hospitals are obscenely expensive in the USA. People who aren’t sick don’t go to hospitals.

    Neither family in the examples above demanded that everything possible be done. Doctors recommended treatments that they thought had a good chance of working.

    Yes, we spend far, far too much on medical care in the US. But I don’t believe it’s being driven by patients and families. It’s being driven by the system that has too many huge costs built-in over the years, and too many interested parties (drug companies, medical equipment suppliers, physicians, etc.) that have figured out ways to collect near-monopoly rents. Doctors don’t know how much stuff costs, patients and families don’t know how much stuff costs nor what should be done. They only have input when things are hopeless.

    My $0.02.

    Cheers,
    Scott.

  10. 10
    Yarrow says:

    Thanks for this post, David. Any thoughts on subsidies still being around in 2019?

  11. 11
    gene108 says:

    @Daddio7:

    Everyone is focusing on how to pay for our medical care, why is no one trying to find out why we spend twice as much as other first world countries for our care?

    There’s no one agency or insurer with the clout and power to tell providers and the consumers, “no, you don’t need this wonder drug/fancy screening test, etc., when the generic and an X-Ray will do”.

    We sort of tried saying ‘no’ in the 1980’s and 1990’s, with the rise of HMO’s and people hated it.

    People in other countries accept their health boards do a cost-benefit analysis before allowing new procedures, treatments, etc. to hit the market, even though they may lose out on something very rare, they know this allows coverage for most people and most conditions.

    We just have not come around to this way of thinking. We want it all.

    Also, when Obamacare was being debated, they said Step 1 was covering everybody and Step 2 would to figure out how to bring costs under control.

    If Democrats had maintained control of government, I think we would see costs being addressed by now, but we have to reinvent the wheel, every time Republicans come to power.

  12. 12

    @Yarrow: highly likely as knocking them out either requires a reconciliation bill or 9 Democratic Senators agreeing to knock them out.

  13. 13
    Raoul says:

    @Another Scott: Yes. And sorry for your losses.

    I didn’t mean to suggest that people refuse treatment, but rather that our system favors most-aggressive, and highest cost (because as you say, costs are hard to find, Dr.s don’t often suggest cost as part of decisionmaking, etc) paths. I may be wrong, but I recall reading some stories about European countries that do treatment planning, especially for the elderly, that looks at cost v outcomes and tries to move people to statistically valid but not most-aggressive treatment plans.

    I don’t think we should railroad folks, patient choice is important, but cost containment I think entails some risks, or quality of life / quantity of life weighing.

  14. 14
    NR says:

    One of the main reasons I supported Obama over Clinton in 2008 was because he supported a public option and opposed an individual mandate.

    And then he got elected….

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