Nice exchanges there, be a pity if anything happened
August 17, 2016 7:39 AM   Subscribe

On August 16, major healthcare provider Aetna announced that it was pulling plans in exchanges under the Affordable Care Act (aka "Obamacare") in 11 states, claiming they were losing (and expecting to lose) too much money under the new law. But the story doesn't end there.

Jonathon Cohn and Jeffrey Young, writing for The Huffington Post, reported that Aetna CEO Mark Bertolini had written a letter the US Department of Justice on July 5. The letter claimed that, if the DOJ didn't approve of their merger with Humana (another large healthcare provider), they would pull out of the exchanges, effectively threatening the exchanges themselves. Before the month was out, the DOJ had filed an antitrust suit against both Aetna and healthcare provider Anthem. However, in at least one major market, Aetna was still making a profit, and is expected to do so next year. What this means for the future of the ACA remains unclear, with both supporters and critics weighing in.
posted by zombieflanders (140 comments total) 42 users marked this as a favorite
 
Isn't this blackmail? Isn't blackmail illegal?
posted by lownote at 7:48 AM on August 17, 2016 [12 favorites]


*cough*singlepayernow*cough*
posted by entropicamericana at 7:49 AM on August 17, 2016 [108 favorites]


The chaos on the exchange markets must be stabilized. If only there was some sort of national coverage program with a large provider network that could be opened up to allow anyone willing to pay into it to enroll. If only.
posted by ThePinkSuperhero at 7:50 AM on August 17, 2016 [49 favorites]


Is Aetna’s withdrawal from the exchanges payback for the Justice Department’s antitrust suit?
That’s why it’s so hard to make out whether Aetna’s threat was sincere or strategic. Maybe its financial situation really has deteriorated as a result of the antitrust suit, so much so that it can’t afford to stay in unprofitable markets. Maybe, though, it had to follow through with the threat to preserve its credibility for future negotiations, even if it’s worse off as a result.

Probably it’s a bit of both. Still, Aetna’s not likely to get the benefit of the doubt. Its pious denials give its behavior a ring of hypocrisy. And there’s something disquieting about its thinly veiled suggestion that the Justice Department should bless anti-competitive conduct for short-term political advantage. Playing hardball with regulators may be common—but it can also be risky.
posted by gladly at 7:51 AM on August 17, 2016 [2 favorites]


What I would love to see is the government step in with a "well, if the market won't provide insurance, we will." Of course, with the Republicans controlling a gerimandered House, this won't happen on a national level. Maybe some of the states will do it though.
posted by Hactar at 7:51 AM on August 17, 2016 [5 favorites]


Aetna claimed That without the merger they wouldn't be able to get the economies of scale necessary to stay in the exchanges. This could be a true statement or it could be a threat. More evidence would be needed to prove this one way or the other.
posted by humanfont at 7:56 AM on August 17, 2016 [2 favorites]


"Aetna's decision to alter its marketplace participation does not change the fundamental fact that the health insurance marketplace will continue to bring quality coverage to millions of Americans next year and every year after that," said Kevin Counihan, the exchanges CEO. "It's no surprise that companies are adapting at different rates to a market where they compete for business on cost and quality rather than by denying coverage to people with preexisting conditions."
So, these are growing pains. Aetna clearly doesn't want to change its business model, where they could opt to only cover patients who were at lower risk for expensive diseases and disorders.
posted by zarq at 7:56 AM on August 17, 2016 [9 favorites]


*cough*singlepayernow*cough*

It sounds like you need something for that cough. That'll be $5,600, please.
posted by winterhill at 7:56 AM on August 17, 2016 [70 favorites]


The lesson is that the private insurance industry was never going to be a reliable partner in this endeavor. (Or, once you've paid the Danegeld, you'll never be rid of the Dane.)

This is why there should have been a public option from the get-go, and why it's increasingly looking like the only way to save the ACA.

Simplest way to achieve that, of course, would be to simply nationalize Aetna and Humana. I mean they can try to bully the federal government if they wish, but ultimately that's sort of like bringing a knife to a gunfight nuclear war.
posted by Naberius at 7:58 AM on August 17, 2016 [39 favorites]


I'm a little confused at how this is even possible. The ACA works because of the individual mandate: everyone MUST have insurance, or pay penalties so steep that they might as well be paying for insurance. That's how you guarantee that your risk pool doesn't bankrupt an insurer. Is there no reciprocal mandate for INSURERS, requiring them to offer to underwrite policies in state exchanges? If not, how did no one see this coming from the word go?
posted by Mayor West at 7:58 AM on August 17, 2016 [14 favorites]


Even before the Aetna bombshell, the news was going around that there would be "substantial"- i.e. "much higher than last year" - premium increases at all the ACA state exchanges. Most beneficiaries will get the bad news right before the enrollment period begins... on November 1st, a week before the election. Can you say "uh oh"?
posted by oneswellfoop at 7:59 AM on August 17, 2016 [3 favorites]


Fuck Anthem. They used to regularly deny refills by "accidentally" un-updating the dosage I was on, they managed to keep me off of SGLT2 inhibitors for 9 months after my doctor tried to prescribe one, and they're cancelling coverage of another one of my meds for 2017 (though there's an almost-equivalent). The last thing I want is for them to grow.

A very real part of why I want single-payer is to watch that company wither and die. (The other parts are to save myself $10,000 a year, and to know that less fortunate friends can actually afford the meds they need.)
posted by Foosnark at 8:00 AM on August 17, 2016 [32 favorites]


This is yet one more critical reason we need to work just as hard on down ballot races right now. With a D majority, it's possible to put pressure on insurance companies to keep them in line. Oh, you don't want to provide service in all counties in all states? Ok, how about you don't provide services anywhere? This type of picking and choosing where you'll do business is SOP for health insurance companies. There are lots of counties here in Florida where you only have one choice as your Medicare plan. If your particular doctor isn't on their list, then too bad for you. Pay out of pocket or change up all your care. Private health insurance companies are barbaric.
posted by hollygoheavy at 8:01 AM on August 17, 2016 [21 favorites]


If not, how did no one see this coming from the word go?

You mean, aside from essentially everyone on the left who predicted this very outcome in the absence of a public option?
posted by enn at 8:01 AM on August 17, 2016 [84 favorites]


The ACA works because of the individual mandate: everyone MUST have insurance, or pay penalties so steep that they might as well be paying for insurance.

According to NPR's coverage, Aetna said not enough healthy people are buying insurance to offset the more costly sick people. As I understand the ACA, penalties for not having insurance started off low but are increasing over time.
posted by entropicamericana at 8:03 AM on August 17, 2016 [3 favorites]


My father worked as an underwriter in the liability insurance business. I spent five years working for a life insurance company. One of the few things that we (as well as most people I know who worked in various insurance businesses, regardless how conservative they were) agreed upon was that "health insurance" was a racket that made the rest of the industry look bad. Quite a lot of support for Socialized Medicine among moneyed Republicans there. The ACA did not fix ANY of the biggest problems with the American Health System and if Hillary and the Democrats don't get ahead of this issue NOW, a lot of people currently relying on the ACA will vote for politicians vowing to repeal it.
posted by oneswellfoop at 8:10 AM on August 17, 2016 [25 favorites]


With a D majority, it's possible to put pressure on insurance companies to keep them in line.

Downballot Democrats like Evan Bayh? He's one of the Blue Dog Democrats who worked so hard last time to water down the ACA.
posted by indubitable at 8:15 AM on August 17, 2016 [8 favorites]


I know a few auto, home, and construction insurance agents and underwriters. None of them ever want to switch to health. They already feel terrible enough having to tell someone that their car or house can't be insured or paid out for, they can't imagine having to tell someone their health can't be paid for. It's a terrible business and I wish all those companies would die for a single-payer system.
posted by numaner at 8:18 AM on August 17, 2016 [17 favorites]


Vs Downballot Republicans for whom Repeal the ACA is the new Bloody Shirt... sure
posted by wotsac at 8:19 AM on August 17, 2016 [4 favorites]


Aetna was a nightmare for my girlfriend to deal with, her doctors finally got her med list dialed in to something she could deal with and then Aetna came along as the new state Medicaid provider and threw a wrench into the whole thing by denying coverage for certain meds and making her jump through hoops, I'm not going to be sad to see them go.

And double-fuck 'em for throwing a tantrum about their inability to make a buck off of the stacked deck of regulatory capture.
posted by jason_steakums at 8:27 AM on August 17, 2016 [2 favorites]


Oh, great... they're still staying in our state. Ugh.
posted by jason_steakums at 8:28 AM on August 17, 2016


January 20, 2017: Hillary turns from the chief justice, grabs the lecturn and says "Medicare for All. By March. Let's do this."

...and then I wake up, really irritated it was a dream.
posted by Mooski at 8:29 AM on August 17, 2016 [6 favorites]


What I've discovered in my search for health insurance is that pretty much all of the insurers I have access to offer the exact same policies directly from them. That is, the silver policy I could get on healthcare.gov is also available directly from the same insurer.
posted by Thorzdad at 8:31 AM on August 17, 2016


>With a D majority, it's possible to put pressure on insurance companies to keep them in line.

Downballot Democrats like Evan Bayh? He's one of the Blue Dog Democrats who worked so hard last time to water down the ACA.


Insert a 'sufficiently large' before 'D majority' if you want -- if there are enough solid votes without needing to entice Democrats on the edge, no one's going to be looking to compromise more than they have to. But regardless of where you want to draw that line (at half-plus-one, or half-plus-ten, etc), it's not going to happen without a Democratic majority. Without a Democratic majority, it's impossible to put much pressure on insurance companies to change, so long as the only drumbeat of reform from the Republican side of the aisle is 'repeal the ACA.' A bare majority means we get something rather than nothing, and, as someone who could not get coverage at all on the open market before the ACA, it has been a huge improvement over what came before. Not what I wanted, but I'm happy to have it.

If you don't like the slate of Democrats in 2016? November is a great time to note only get out and vote, but to start thinking about the 2018 primaries and the midterm elections. Pay attention to who's talking about running in your area. Volunteer, write letters, donate. Tell your current representative that you'll be watching their votes on ACA reform bills and that it's a big issue for you going into the next primary.
posted by cjelli at 8:32 AM on August 17, 2016 [13 favorites]


As I understand the ACA, penalties for not having insurance started off low but are increasing over time.

One uninsured person I know, who could have insurance through his employer but it would pretty much take half his income every month for a family plan, says it'll be a looooooong time before the penalties get anywhere near making paying for insurance look like the better option. I know, he's asking for a broken leg to bankrupt him, but he negotiates a cash price with the doctor every time so between his annual medical expenses, plus the ACA penalty, does look like a smart financial decision on paper given the cost of insurance for his household. I had high hopes for the ACA, but it still leaves wide swaths of people for whom their income/vs/healthcare costs isn't "bad enough" that the ACA benefits them.
posted by AzraelBrown at 8:32 AM on August 17, 2016 [6 favorites]


not enough healthy people are buying insurance to offset the more costly sick people

Well d'uh. Healthy people are already covered because they have jobs that provide them with health coverage and so they can go to the doctor when they need to. That's why they're healthy.

I mean it's not as though the very foundation of the private insurance business isn't exhaustively detailed demographic statistics and intense, cutting-edge data analysis in order to carve out mind-numbingly detailed and precise actuarial projections for any population segment imaginable. I refuse to believe they were somehow taken by surprise by the idea that people without health coverage were going to be poor, that they were going to have a lot of health issues, and that they would be correspondingly more expensive to cover.
posted by Naberius at 8:32 AM on August 17, 2016 [29 favorites]


Downballot Democrats like Evan Bayh? He's one of the Blue Dog Democrats who worked so hard last time to water down the ACA.

And yet, the big conservative PAC supporting his opponent are making a big deal over Bayh "casting the deciding vote for Obamacare." Yeah, Bayh is far from being a liberal (unlike his father, Birch) but, he's the best we can get this year.
posted by Thorzdad at 8:35 AM on August 17, 2016 [1 favorite]


Some thoughts in no particular order:

1) 6 of the 11 states where Aetna is pulling out have declined the option to expand Medicaid. The states Aetna is leaving: (with Medicaid expansion) Arizona, Kentucky, Pennsylvania, Illinois, Ohio & (without) Florida, Missouri, South Carolina, Georgia, North Carolina, Texas (states source & medicaid status source).

2) Aetna claims their inability to pool insurance risks across state lines is a contributing factor & this is a natural outcome. However, Aetna themselves do not pool their insurance risks between "traditional" policies & ACA policies, such that they are $10bn profitable in toto but claim a loss of $200mi in their ACA silo.

3) Aetna is on record threatening to pull out of ACA markets contingent on an unfavorable anti-trust ruling.

4) Aetna is prospering well enough to buy Humana & consolidate.

5) Aetna's most recent quarterly report beat expectations (source).

Am I missing something?

It occurs to me that the simple solution (and I don't understand why this would not have been an operating requirement) would be that in order to offer any insurance services in a state (corporate/employer-provided, etc.) one would necessarily participate in the ACA markets. It seems positively ludicrous that an insurance company can chase "healthy"/profitable markets in a state without providing options on the ACA.

Did anyone ever believe that an ACA-only market of under-employed (and therefore likely low-income & thusly health challenged [because it's hard to be healthy when money that might be earmarked for diet/exercise/wellness is shuffled around for rent/debt/emergency expenditures]) people would be profitable in & of itself? I thought the idea was always that folding more & more people into the health insurance collective would help subsidize those with pre-existing conditions, etc. Of course a strict pool of only the poor, aged, & sick isn't profitable.

I'm no expert, though. If anyone can further elucidate, I'd be grateful.
posted by narwhal at 8:35 AM on August 17, 2016 [68 favorites]


January 20, 2017: Hillary turns from the chief justice, grabs the lecturn and says "Medicare for All. By March. Let's do this." ...and then I wake up, really irritated it was a dream.

Hillary Clinton has been very clear from the outset that she does not intend to rock the ACA boat. You must be thinking of Bernie ("Bro") Sanders.
posted by splitpeasoup at 8:37 AM on August 17, 2016 [22 favorites]


I first became aware of Humana when Michael Moore did a segment on them on his short-lived Awful Truth. The segment was about a guy who was denied a pancreas transplant by Humana, his HMO. The alternative to the transplant was waiting to die.

I am here from an alternate reality to tell you that people who say single payer is a terrible idea is a lying liar who tells lies - I speak as someone who has watched friends with complex and chronic illness get treated by the system I'm covered under. Family members have been cared for by the system in the final moments of their lives.

Is it some perfect, magical fantasy land where no-one gets sick, dies, or encounters bureacratic hurdles or errors that result in bad outcomes, frustration, or delayed care?

Of course not.

What single payer means is that, generally speaking, seeking medical treatment is not a game of Russian roulette with personal bankruptcy.
posted by mandolin conspiracy at 8:40 AM on August 17, 2016 [22 favorites]


If not, how did no one see this coming from the word go?

You mean, aside from essentially everyone on the left who predicted this very outcome in the absence of a public option?
posted by enn at 8:01 AM on August 17 [17 favorites +] [!]


Wait didn't we all agree this was going to happen? Just we disagreed (along, it seems, incrementalist vs...uh, absolutist*, I guess? lines) about how in the end to get to single-payer?

I mean, the left is on offense right now. There's no reason we can't use this to say, look at what the Republicans would do to your healthcare, we need to expand the ACA and we need Democratic majorities to do it.

*there has got to a better word for this, I apologize for not knowing it in advance
posted by schadenfrau at 8:43 AM on August 17, 2016 [3 favorites]


Hillary Clinton has been very clear from the outset that she does not intend to rock the ACA boat. You must be thinking of Bernie ("Bro") Sanders.

Nah, I was thinking of the President of the United States. That'd be Hillary.
posted by Mooski at 8:43 AM on August 17, 2016 [5 favorites]


This is fascinating! I saw that they were trying to get out of the less profitable markets, but not that they were trying to get some antitrust stuff dropped in order to do so.

Honestly, this is a predicted failure point of the ACA. Both Republicans and Democrats predicted this one - Republicans said it was a reason to ditch the whole thing, while Dems said that it was the reason to create single payer, but everyone knew that this Frankenstein monster would have major issues.
posted by corb at 8:50 AM on August 17, 2016 [8 favorites]


What ever happened to "fixing" the egregious over charges and waste in the industry?
posted by sammyo at 8:55 AM on August 17, 2016 [6 favorites]


Here is a story about bitter irony.

I spent a year and a bit on Pennsylvania Medicaid while I went to school full time and had no income. As a reasonably healthy person, it was great! I was able to get all the medications I need with no problems, and my regular doctor's practice takes a lot of Medicaid patients and knows how to deal with any bureaucracy that came up. (I grant though, that I have the privilege of living in a major city with a variety of Medicaid providers.)

Then I graduated from school, got my nursing license, and got a job! After years of office temping and shitty sales gigs, nursing wages are amazing!

Except that my job, in their infinite cheapness, hired me and most of the others in my orientation group as PRN providers with no benefits. The Wal Mart model of healthcare. Newly employed, making more than I've ever made in my life, and about to lose my insurance because I actually make a living wage. Thanks US healthcare system!

So I need to go to the exchange for a plan. Fine, I've done this rodeo before, it's inconvenient but given the variety of horrible pathogens I'm exposed to in my work I need coverage. Except now with Aetna pulling out of PA my options there are slashed as well. Great!

For-profit medical models got me into this boat on both counts. My workplace (or rather, their parent company) wants to squeeze out every dollar they can, so they skimp out on full time nurses, techs, social workers, you name it. Aetna wants to squeeze out every dollar they can, so they pull out of the market and throw a tantrum about how they're losing so much just by doing their job of covering sick people. In what other industry does actually doing your job make the CEO throw a shit fit?

Burn it all down. Single payer sometime in my lifetime please.
posted by ActionPopulated at 8:58 AM on August 17, 2016 [58 favorites]


Wait didn't we all agree this was going to happen? Just we disagreed (along, it seems, incrementalist vs...uh, absolutist*, I guess? lines) about how in the end to get to single-payer?


Hillary Clinton: "single payer will never ever happen.
posted by ennui.bz at 9:00 AM on August 17, 2016 [21 favorites]


I keep thinking about Joe Biden talking about Trump's trademarked catch phrase, "You're fired!"

"Think about that. Really think about it."

It seems even more appropriate if you applied to the idea that human suffering should be a profit center.
posted by schadenfrau at 9:03 AM on August 17, 2016 [1 favorite]


Wait didn't we all agree this was going to happen? Just we disagreed (along, it seems, incrementalist vs...uh, absolutist*, I guess? lines) about how in the end to get to single-payer?


Hillary Clinton: "single payer will never ever happen.
posted by ennui.bz at 9:00 AM on August 17 [+] [!]


Heh. I meant more the hoi polloi on places like MetaFilter, not politicians on the left.

I still hope she's very wrong, but her vast amount of experience with healthcare in the US makes me...really sad about that. Regardless, people would have said many things were never going to happen through out our history, even the people who were fighting for them. Just because an ideal seems out of reach doesn't mean you stop fighting for it, which...I mean I've always taken that as a given as part of my pragmatism, but I gather that isn't always a sentiment that is shared.
posted by schadenfrau at 9:06 AM on August 17, 2016 [1 favorite]


Hillary Clinton: "single payer will never ever happen.

In context:
"I want you to understand why I am fighting so hard for the Affordable Care Act...I don't want it repealed, I don't want us to be thrown back into a terrible, terrible national debate. I don't want us to end up in gridlock. People can't wait!...People who have health emergencies can't wait for us to have a theoretical debate about some better idea that will never, ever come to pass."
She's saying that she'll concentrate, and that we should concentrate, on real changes we can effect now, because people are sick and hurting now, and put her political capital behind whatever can happen now. She's not saying she's against single payer, on principle, she's saying she's uninterested in debating whether or not Single Payer is, in principle, better or not because she's not interested in what's better in principle. She's interested in what's better in practice, within the scope of what can happen. Rhetorically, 'never, ever come to pass' is, pretty clearly, 'in the next four years': she was specifically responding to Sander's call for single payer during his presidency. 'Never, ever come to pass' during the next presidency is very different than literally never.

Clinton is certainly not pushing for single-payer (which I, personally, am disappointed by, but); she's pushing for a public option. But I think it's a mistake to think that that stems from an opposition to single payer in principle, or a belief that it won't happen; I think it stems from her work in the field, and her belief in what's possible in the next four years.
posted by cjelli at 9:14 AM on August 17, 2016 [54 favorites]


The ACA did not fix ANY of the biggest problems with the American Health System and if Hillary and the Democrats don't get ahead of this issue NOW, a lot of people currently relying on the ACA will vote for politicians vowing to repeal it.

The problem for single-payer advocates is that you are effectively arguing that the problems with the US healthcare industry are problems of economic demand:

1) there isn't enough demand for healthcare because lots of people can't afford it

2) pricing is inefficient ie. too high because of the way payments in the health care industry work.

But there are huge *structural* problems with the supply of health-care in the US ranging from how big pharma is "regulated" to the supply of doctors, the distribution of doctors geographically, and so on.

When you advocate for "single-payer" you are saying that if one entity controls the price of health services, then all of these problems can be solved. That is, the government has taken political responsibility for all of the problems of the industry. Except that if that government can't directly modify the way the supply of health care services is structured, it has one (or maybe two) hands tied behind it's back. If payments are too low, local hospitals close, practitioners move, drug supplies dry up, etc. So, government has all of the responsibility but only one tool for dealing with all of the problems: price. Because, the US already spends more per capita than any other nation. Single-payer is ultimately the argument that if the government just controls the price, then the "market" will supply what everyone needs.

The US needs a "national" health care system more than it needs to get rid of private health insurance. Single-payer is just empty political rhetoric from liberals who want to avoid the uncomfortable fact that system for the supply of health services is increasingly close to collapse and the only way to solve this is for the government to directly intervene by changing the way drugs are funded, the way doctors are educated, and to build hospitals and clinics.
posted by ennui.bz at 9:18 AM on August 17, 2016 [21 favorites]


Hillary Clinton: "single payer will never ever happen.

I'm sorry but this is intellectually dishonest and taken out of context. Hillary Clinton was speaking purely in a pragmatic sense. She's tilted at this windmill multiple times. She lost the biggest battle, won a smaller battle and is leading the side that is slowly winning the war. She knows what it takes to get single payer and she knows it won't happen. She's entirely correct.

Even a double digit house swing won't get us single payer healthcare because in many districts the choice is between blue dogs and Republicans, neither of which are going to vote for single payer healthcare.
posted by Talez at 9:26 AM on August 17, 2016 [20 favorites]


Hillary Clinton: "single payer will never ever happen."
Rhetorically, 'never, ever come to pass' is, pretty clearly, 'in the next four years': she was specifically responding to Sander's call for single payer during his presidency. 'Never, ever come to pass' during the next presidency is very different than literally never.

I find this sort of internal rationalization fascinating. In every day life "never ever" has a pretty clear meaning, but if you want to believe something about Clinton and the Democrats, you easily transform "never-ever"'s meaning into the opposite. I guess you can claim she's just being inarticulate. But ask yourself, why would she make this statement? It would be easy for her to say what you have suggested. Answer: because she wants to build political coalitions with people who are completely opposed to single-payer ie. the AMA and/or Republicans. Same way the public-option was still-born by the Obama's desire to make a political coalition with health insurance companies... and you can see exactly how that worked out.
posted by ennui.bz at 9:28 AM on August 17, 2016 [17 favorites]


The US needs a "national" health care system more than it needs to get rid of private health insurance. Single-payer is just empty political rhetoric from liberals who want to avoid the uncomfortable fact that system for the supply of health services is increasingly close to collapse and the only way to solve this is for the government to directly intervene by changing the way drugs are funded, the way doctors are educated, and to build hospitals and clinics.

I agree on the first point, and virulently disagree on the second. First, most people are going to be ignorant of even the basics of these policies; for the most part these phrases stand in for general feelings about an issue. Second, supporting single-payer is not something anybody does in a vacuum. A wholesale revolution in the structure of US healthcare would be incredibly, messily destructive in the short term. So, many people take the best they can get, or support the most realistic or least-destructive goal that is closest to their own ideal, and then hope to use every last little bit of progress towards their position to leverage further progress. That does not make them uncomfortable or incapable of facing reality. That makes them intent on doing the best they can right now.
posted by schadenfrau at 9:29 AM on August 17, 2016


Oh god. I have a lot of things to say but I have to go away for the next couple hours.

Here is the best backgrounder in my opinion. Then read this for, uh, a little bit of the political background.
posted by tivalasvegas at 9:31 AM on August 17, 2016 [6 favorites]


Omg the health insurance nightmare in this country just keeps getting worse.
posted by freakazoid at 9:34 AM on August 17, 2016


Here is Hillary's actual health policy platform, from her campaign website. Key relevant points include plans to:

- Defend against Republican attacks on the ACA and expand it to include a public option, including Medicare for those over 55;
- Reduce co-pays and deductibles;
- Reduce prescription drug costs;
- Offer incentives to encourage more states to expand Medicaid and simplify enrollment in Medicaid and ACA plans;
- Open ACA availability to everyone regardless of immigration status;
- Identify ways to improve health care access to those who live in rural areas, which are a huge stumbling block for single payer viability [my editorial comment];
- Increase funding for community-level services and the health care workforce.

This does not read as the platform of someone in the pocket of Big Insurance. It also doesn't suggest she's unwilling to interfere with the ACA: she wants to improve upon it, rather than burn it to the ground and start this battle from scratch, which would lay waste to the massive political capital Obama and the Democratic Party spent on getting something, anything enacted (and defending it from a gazillion spurious lawsuits).
posted by Superplin at 9:34 AM on August 17, 2016 [14 favorites]


Aetna's reply to my appeal of their denial for my short term disability said "Your disability was well documented but we're screwing you on a technicality and if you don't like it, sue us." Although I'm paraphrasing, that was really the gist of the letter. Fuck Aetna.
posted by Ruki at 9:35 AM on August 17, 2016 [6 favorites]


Single-payer is ultimately the argument that if the government just controls the price, then the "market" will supply what everyone needs.

Eh, it's no different than the argument that private insurers paying hospitals less for procedures causes those hospitals to, in turn, charge less for those procedures. When in reality, it just means higher premiums and costs for patients.

Single payer gets us closer to price transparency, which would cut out an inefficient profit-making middleman. It's a shame we have a candidate who has used clear language to express her dismissal of it, because it's a sad state of affairs to otherwise allow an insurance company to blackmail the United States and call that kind of outcome "pragmatic".
posted by a lungful of dragon at 9:37 AM on August 17, 2016 [5 favorites]


First, most people are going to be ignorant of even the basics of these policies; for the most part these phrases stand in for general feelings about an issue. Second, supporting single-payer is not something anybody does in a vacuum. A wholesale revolution in the structure of US healthcare would be incredibly, messily destructive in the short term.

One of Sander's big accomplishments was getting $10 billion for community health centers, from a Republican controlled House. In a way, I actually agree with Clinton that single-payer is never going to happen as long as the Republican party exists. But you can actually create a national health care system piece by piece, and as the private system collapses the demand (and political support) for that system will only grow.

Also, lowering the Medicare age to 55 would be a gigantic subsidy for the private health insurance industry as it would take people out of the private system after they've paid an enormous amount into the system and their demand for health services starts to increase dramatically.
posted by ennui.bz at 9:38 AM on August 17, 2016 [10 favorites]


Hillary Clinton has been very clear from the outset that she does not intend to rock the ACA boat.

There's a difference between not intending to rock the ACA boat (which I agree she doesn't) and dealing with someone else who is trying to capsize it. And she's pretty much an incrementalist.
posted by Francis at 9:51 AM on August 17, 2016 [2 favorites]


The US needs a "national" health care system more than it needs to get rid of private health insurance. Single-payer is just empty political rhetoric from liberals who want to avoid the uncomfortable fact that system for the supply of health services is increasingly close to collapse and the only way to solve this is for the government to directly intervene by changing the way drugs are funded, the way doctors are educated, and to build hospitals and clinics.

No objection there, either, from the we-have-single-payer side of the fence. The government can and does build hospitals, clinics, regional health systems/networks, etc. But there are also private clinics that deliver health care as well, reimbursed by the single-payer government insurer (so, to the people who claim there's no "choice" in healthcare providers under Canada's "socialized medicine," the answer is "there's a lot, actually" - although regional disparities do exist because Canada's population is small and widely spread over a large area).

So just to be clear, under the Canadian system, the government can and does intervene heavily on the service provision supply side as well.
posted by mandolin conspiracy at 9:54 AM on August 17, 2016 [12 favorites]


It was expected that lots of smaller employers would give up their group plans -- which require in-house admin overhead and can sometimes be affected from year to year by a single employee's health problems -- and instead encourage employees to go with Exchange plans that they'd then reimburse. That hasn't happened. This means that the ACA risk pools are narrower than expected.

Still, the for-profit insurers are making money hand-over-fist on group plans, and they're looking at a standard Wall Street M&A consolidation strategy to line their own pockets.

In a sane political climate, the problems with the exchanges would be addressed by tweaks to the ACA (particularly risk corridor adjustments) based upon how it's worked in practice. But this isn't a sane political climate.

Anyway, fuck Aetna, and let's see what happens in 2017 when many states will end up with monopoly Exchange-compliant insurers who will then probably attempt to play chicken with the federal government and state commissioners of insurance with the threat of leaving in 2018. It drives home the need for legislative majorities that at very least aren't made up of nihilists.
posted by holgate at 10:05 AM on August 17, 2016 [7 favorites]


Hillary Clinton: "single payer will never ever happen.

For what it's worth, the full quote is "I want you to understand why I am fighting so hard for the Affordable Care Act. I don't want it repealed, I don't want us to be thrown back into a terrible, terrible national debate. I don't want us to end up in gridlock. People can't wait! People who have health emergencies can't wait for us to have a theoretical debate about some better idea that will never, ever come to pass." Which has a somewhat different connotation than the abbreviated quote (as is often the case).
posted by aught at 10:08 AM on August 17, 2016 [19 favorites]


>And she's pretty much an incrementalist.

It's possible that she shares the values and goals of people who want accessible health care for all, but who believes that incrementalist methods are the only or best tool for realizing those values. Alternately, it's possible that she's a centrist who believes that some incremental fixes are necessary to the current system, but that fundamentally the current system is preferable to nationalized or semi-nationalized health care for all. A mistake many people on the left make is in assuming that most people share their values, but differ on how those values are to be implemented. Instead, we're a country where ordinary people and elected officials alike have diverse sets of values and goals, many of which are at odds with each other.
posted by You Can't Tip a Buick at 10:10 AM on August 17, 2016 [17 favorites]


I think it's utterly implausible, however, that we will find ourselves in a situation where Hillary Clinton is trying to argue down a massive popular groundswell of support for nationalizing healthcare.
posted by Zalzidrax at 10:20 AM on August 17, 2016 [12 favorites]


Yeah Obama already ignored that and saved all his political capital to fight for the TPP instead.
posted by dame at 10:36 AM on August 17, 2016 [1 favorite]


God, and people wonder why some are disillusioned with capitalism. Companies make money by denying people expensive health care they need, how the hell did we get to this point?
posted by Brandon Blatcher at 10:37 AM on August 17, 2016 [4 favorites]


Honestly, this is a predicted failure point of the ACA. Both Republicans and Democrats predicted this one - Republicans said it was a reason to ditch the whole thing, while Dems said that it was the reason to create single payer, but everyone knew that this Frankenstein monster would have major issues.

Calling it a Frankenstein monster is just more anti-ACA messaging tactics. The ACA is a big law with a wide scope. Every time someone - left or right - sneers at it based on one aspect, like exchanges or medical device tax or whatever, they make themselves look kinda dumb. There's a lot of there there, ranging from creating the exchanges to removing out-of-pocket costs for health visits (a pro-proactive/checkup measure) to a laundry list of things meant to help bend the cost curve. All the we knew it! from any side just looks dopey.

On the messaging front, I hereby grant anyone who wants to call it a Frankenstein monster the freedom to do so provided they are consistent in talking about the Defense appropriations bills and Farm bills that way also. Otherwise they should STFU.
posted by phearlez at 10:38 AM on August 17, 2016 [6 favorites]


I hereby grant anyone who wants to call it a Frankenstein monster the freedom to do so provided they are consistent in talking about the Defense appropriations bills and Farm bills that way also

Happily.
posted by entropicamericana at 10:40 AM on August 17, 2016 [6 favorites]


"People who have health emergencies can't wait for us to have a theoretical debate about some better idea that will never, ever come to pass."

And for the life of me, I can't see why she wouldn't want to stick her hand on the red-hot burner. Again

I mean, does anyone else here remember what happened the last time Hillary touched health care reform? The demonization of her that's lasted 20 yeasts?

If she touches health care reform, historians 2000 years from now will consider her another Caligula, just based on the Twitter posts and Breitbart articles about her.
posted by happyroach at 10:43 AM on August 17, 2016 [2 favorites]


to removing out-of-pocket costs for health visits

But for many people it hasn't. Overall, for many people, it has made healthcare worse. I pay more money for less care — and so do most people I know. The insurance I am mandated by law to buy costs me ~$40k a year before they start paying anything. And that was the cheapest option! That is just a fact. If you can't address that, then just yelling at people because they object to a law that has made their lives worse seems not a great way to get them on your side. I am okay with paying a little more to cover everyone; but that doesn't extend to lining private pockets, creating caps that make no sense in urban areas, refusing to negotiate drug prices, and just taking it because "bad people don't even want you to have this."
posted by dame at 10:45 AM on August 17, 2016 [8 favorites]


Uh, that should say $10k. It's still a lot but don't wanna lie.
posted by dame at 10:46 AM on August 17, 2016 [2 favorites]


I hereby grant anyone who wants to call it a Frankenstein monster the freedom to do so provided they are consistent in talking about the Defense appropriations bills and Farm bills that way also

Happily.


Just be clear the message you send when you play along with this messaging - it's a don't try big things conservative message. I have a lot of problems with the nature of what's in defense and agriculture spending. But attacking large bills for nothing more than being large is pure traditional conservatism. It is standing athwart any legislative changes and yelling stop.

If that's your political ideology, have at it. As a middle-grounder I am all in favor of asking large and/or expensive efforts to defend themselves as being worth it. But I still believe in the ability of government to improve society, so I will not sit quietly while people uncritically use the language of those who oppose all efforts on basic principle.
posted by phearlez at 10:48 AM on August 17, 2016 [4 favorites]


i was gonna say shit 40k if you wanna take some drs hostage in a supervillain complex or something i got your back
posted by poffin boffin at 10:48 AM on August 17, 2016 [14 favorites]


then just yelling at people because they object to a law

You're looking at the wrong goalposts if you're addressing that to me. I have a problem with dismissing the entire ACA based on one item, as was happening above, as well as denigrating it for its scope.

There's lots of good conversations to have about aspects of it that, in a sane Congress, would have been addressed and amended. That's not what I was talking about.
posted by phearlez at 10:51 AM on August 17, 2016 [1 favorite]


> I think it's utterly implausible, however, that we will find ourselves in a situation where Hillary Clinton is trying to argue down a massive popular groundswell of support for nationalizing healthcare.

Absolutely. One other thing that people on the left in the United States often don't get is that the U.S. is on the whole not a particularly good country, and Americans on the whole genuinely don't want particularly good things for each other. We're a "red in tooth and claw" type of place, and anything that ameliorates widespread suffering is to most Americans suspect specifically because it ameliorates widespread suffering.

On the whole, we like that this country sorts winners from losers, elect from preterite, and we like it when the preterite suffer grotesquely.
posted by You Can't Tip a Buick at 10:55 AM on August 17, 2016 [26 favorites]


And for the life of me, I can't see why she wouldn't want to stick her hand on the red-hot burner. Again

Whoever is running things, whoever it is, has to deal with Big Societal Issues, like healthcare. Part of the job is dealing with the messy problems that come up, like confronting businesses that blackmail our legal system.
posted by a lungful of dragon at 10:56 AM on August 17, 2016 [7 favorites]


It was expected that lots of smaller employers would give up their group plans -- which require in-house admin overhead and can sometimes be affected from year to year by a single employee's health problems -- and instead encourage employees to go with Exchange plans that they'd then reimburse. That hasn't happened.

if Obama and the Democrats had campaigned on destroying group insurance for small business, they would have lost all of congress and the presidency in 2012. so you can bet that was one of the reasons it didn't happen. the ACA left a lot of hard decisions to panels of "experts" after the bill was passed who no doubt responded to their respective sponsors... and in the end, even the ACA silver plans are deeply flawed, much less the brown bronze plans ie. the plans small business employees would be pushed into.

there's really no honest analysis of the health care industry in the US which says anything other a radical overall of private insurance ala the German model, would solve any of the fundamental problems. the ACA is defined by a political alliance between the Democrats and the insurance industry which basically promised magic to the various constituencies: health care for all! keep your current plan! profits for all!

it's just wrong headed to think that "tweaks" are going to fix something built on a huge contradiction.
posted by ennui.bz at 10:57 AM on August 17, 2016 [3 favorites]


Aetna would sooner slit their own throats before paying a claim.

Let 'em go, then prosecute them for extortion under RICO.
posted by prepmonkey at 11:01 AM on August 17, 2016 [5 favorites]


One other thing that people on the left in the United States often don't get is that the U.S. is on the whole not a particularly good country, and Americans on the whole genuinely don't want particularly good things for each other. We're a "red in tooth and claw" type of place, and anything that ameliorates widespread suffering is to most Americans suspect specifically because it ameliorates widespread suffering.

This is reductive and unfair and really kind of gross.
posted by psoas at 11:13 AM on August 17, 2016 [12 favorites]


I mean I don't like it either.
posted by You Can't Tip a Buick at 11:14 AM on August 17, 2016 [13 favorites]


You Can't Tip a Buick, where is the evidence that, specifically in healthcare, Americans don't support a single payer option that provides healthcare for their fellow citizens?

Every recent poll I've seen indicates that Americans overwhelmingly support a universal option.
posted by kyp at 11:25 AM on August 17, 2016 [3 favorites]


Nothing to panic about here. Aetna is just making a power play. There are other insurance companies that will move in to take up the space. The dickish part of this is that Aetna deliberately waited until the last minute to make their announcement in order to make it difficult for competitors to move in.

There is a long process each year where insurance companies make their computer projections based on last year's experience and have to get their bids to the state insurance commissions in May. It then takes several months of evaluation by the insurance commissioners before the new plans and prices come out in September. Aetna knew their intentions back in May, but they played along, faking it and waited until the last minute to announce their withdrawal to cause the maximum amount of chaos in the competition.

So let Aetna go. Goodbye and good riddance. There will be some temporary disruption but other insurance companies will fill the gap.
posted by JackFlash at 11:29 AM on August 17, 2016 [5 favorites]


Something to note is that all of the states Aetna is pulling out of are controlled by Republican legislatures that are hostile to the ACA and want it to fail, the exception being Illinois that has a Republican governor who appointed the insurance commissioner.

One important point that is often misunderstood is that the ACA health insurance program in your state is managed by your state insurance commissioner, not by the Feds. The Feds only provide the web site and the subsidies, but your state insurance commissioner controls how many insurers there are in your state, the type of networks they have and the prices they charge.

Your state insurance commissioner is probably the most important government official you have never heard of. In some states the commissioner is elected and others appointed by the governor.

States with strong, populist commissioners like California and Washington have very robust, highly competitive insurance markets with dozens of options. States like Georgia or Tennessee with industry toadies for insurance commissioner -- well it sucks to be you as a health insurance customer.

So this Aetna fiasco isn't representative of any failure of the ACA. It just indicates that the health insurance market is still at the mercy of your state representatives. If you had good representatives, you would have good insurance. Getting good stuff is always about getting the votes.
posted by JackFlash at 11:45 AM on August 17, 2016 [27 favorites]


Fuck you Aetna. One of my worst experiences ever. We can't put health insurance companies out of our misery fast enough.
posted by mikelieman at 11:49 AM on August 17, 2016 [1 favorite]


> Every recent poll I've seen indicates that Americans overwhelmingly support a universal option.

maybe we're not awful. maybe we're just disenfranchised. That's what I used to think, at least. Nevertheless, I suspect that it may be useful to not assume that we have a natural tendency toward decency, but that instead decency is something that we must try to diligently, slowly help each other build toward, without indulging in utopian fantasies that we'd really truly be decent if only our leaders let us.

For whatever it's worth, I regret framing this in terms of America and Americans, although I do think that the tendency toward tribalism among (especially) white Americans results in our dark natures coming out more viciously than it does in other first-world countries. Well, okay, and it may also have something to do with our still-present Puritan heritage — I think that's something I was nodding toward with my use of the terms "preterite" and "elect."
posted by You Can't Tip a Buick at 11:50 AM on August 17, 2016 [8 favorites]


The APE - American Puritan Ethic - still has a great deal of influence over our politics and social culture. Any time an aspect of politics seems to make no sense, look to the APE to find a source for it: see if it ties into "sexuality and pleasure, which mostly belong to women, are evil" or "hard work brings rewards, so anyone who is poor must be lazy" and related memes.
posted by ErisLordFreedom at 12:19 PM on August 17, 2016 [4 favorites]


I find the back-and-forth about what Clinton really believes in her heart of hearts mystifying. I mean, as with the debate about whether Trump is "really" a racist, or just sees an advantage in appealing to racists—who gives a shit? We're discussing these people's merits as political leaders, not whether they are in a state of grace with the Lord. Let's judge them on their fucking words and actions. Clinton has made it very clear that she will not support any kind of national healthcare system with her words and actions.
posted by enn at 1:24 PM on August 17, 2016 [3 favorites]


And for the life of me, I can't see why she wouldn't want to stick her hand on the red-hot burner. Again

I mean, does anyone else here remember what happened the last time Hillary touched health care reform? The demonization of her that's lasted 20 yeasts?


This is why I'm disappointed by Clinton's candidacy. The political realities have changed, the electorate has changed, the economy has changed, the range of what is possible has changed—but Hillary Clinton is still fighting the last war (specifically, the 1994 mid-term elections).
posted by enn at 1:28 PM on August 17, 2016 [2 favorites]


This is why I'm disappointed by Clinton's candidacy.

K.
posted by Potomac Avenue at 1:32 PM on August 17, 2016 [2 favorites]


anything that ameliorates widespread suffering is to most Americans suspect specifically because it ameliorates widespread suffering.

I understand this despair, but I think it's just not true. A lot of Americans have complicated feelings about the tradeoffs involved, but I don't think, even in our darkest timeline, that Americans have just wanted to preserve suffering for suffering's sake. I think when you fall into that despair, it just doesn't take any of us to a good place.
posted by corb at 1:33 PM on August 17, 2016 [5 favorites]


> A lot of Americans have complicated feelings about the tradeoffs involved, but I don't think, even in our darkest timeline, that Americans have just wanted to preserve suffering for suffering's sake. I think when you fall into that despair, it just doesn't take any of us to a good place.

One of the many, many advantages about being male, white, cis, and het is that other people who fall into those categories of privilege often assume that I'm like them, and as such don't hesitate to tell me what they really think. So I'll have to disagree with you here.

On the bright side, I guess, I'd say on the whole that most of us are more into passive depraved indifference rather than active sadism; we like watching others swing the whip, but get squeamish when asked to swing it ourselves.

What the Christians used to call the "abominable fancy" — the belief that one of the best pleasures of heaven is getting to watch the suffering of the damned in hell — is alive and well in America.

Shrug. We're both people who find ourselves in the awkward position of sincerely, deeply praying that Hillary Clinton becomes president. This isn't a time for hope in the angels of our better natures, it's a time for mitigating the damage that our collective unleashed id wants to cause.
posted by You Can't Tip a Buick at 1:46 PM on August 17, 2016 [3 favorites]


that Americans have just wanted to preserve suffering for suffering's sake.

Perhaps not, but they do argue that the suffering is what causes people to make better choices that will allow them to be as prosperous as others by learning the value of a hard day's work, not depending on government programs to take care of their basic needs, etc. You may see a large gulf between explicitly wanting people to suffer and merely seeing their suffering as means to an end where suffering is lessened through the power of market forces and can-do spirit, but it still leads to people suffering now based on ideological first principles.
posted by tonycpsu at 1:51 PM on August 17, 2016 [2 favorites]


I find all this so depressing. I'm in Texas, and have been on ACA plans for a couple years. While I'm deeply grateful for the ACA for keeping me and my husband alive during a period of employment instability, the chaos of the plans is insane.

The last time I enrolled (after losing access to yet another employer based plan) (I've honestly had like 6 different plans in the last two years), the only plan I could find that would cover us sufficiently and affordably was a Blue Cross Blue Shield Advantage plan. BCBS is one of the few companies left in Texas on the ACA. It turns out, however, that no providers take this HMO. My primary care doctor does, but my specialists don't. I recently waited three months for an appointment with my gynecologist, who was listed as covered on the plan's website. When I showed up, I was told they don't take that plan. She only accepts that plan at a different clinic for low-income pregnant women. (I'm not pregnant, so I don't qualify.)

I'm currently trying to find a facility to have a thyroid test done that takes my plan....And I was referred to an endocrinologist but there's not one within 100 miles that takes the plan. There are only 10 in the entire state of Texas, according to the website. (Yes, I know I can call and get them to approve someone local, thanks to the ACA.) But it's intensely frustrating.

Sorry, just....grr. This kind of game playing should not be allowed when you're talking about people's health.
posted by threeturtles at 1:57 PM on August 17, 2016 [12 favorites]


I guess the one thing that gives me hope about some modicum of health insurance reform eventually coming to America, (slash, the one thing that makes me think that we'll do our best to keep insurance companies from sabotaging the ACA) is that the pain is inflicted so broadly and so indiscriminately that respectable people fear that they themselves may become victims. In other contexts — for example, the prison system — the torment is targeted such that respectable people don't think they'll get caught in it, and so they're willing to pay top dollar to ensure that their abominable fancy is as abominable as they can make it.
posted by You Can't Tip a Buick at 2:10 PM on August 17, 2016 [11 favorites]


I don't think, even in our darkest timeline, that Americans have just wanted to preserve suffering for suffering's sake.

American culture is heavily rooted in Calvinism. No, really. Keeping people sick and destitute and miserable (especially those who deserve it for various religious reasons) is one of this country's core cultural principles since the settlers showed up in 1600s.
posted by a lungful of dragon at 2:11 PM on August 17, 2016 [2 favorites]


Ok, ok. I see y'all don't want to talk about healthcare, you just want to rehash Bernie vs Hillary. *goes back to the election threads*
posted by threeturtles at 2:15 PM on August 17, 2016


Well yes but also Calvinism is just an expression of dark human desires, rather than necessarily being the root cause of them. No matter what your belief system, you can find a version of the abominable fancy that suits it. Like, lots of nice polite atheists under Stalin, without a Calvinist in sight, took pleasure in the knowledge that the Party was giving those damned kulaks and wreckers and Ukrainians what they deserved.
posted by You Can't Tip a Buick at 2:18 PM on August 17, 2016 [2 favorites]


Ok, ok. I see y'all don't want to talk about healthcare, you just want to rehash Bernie vs Hillary. *goes back to the election threads*

wat
posted by tonycpsu at 2:19 PM on August 17, 2016 [1 favorite]


I thought the idea was always that folding more & more people into the health insurance collective would help subsidize those with pre-existing conditions, etc. Of course a strict pool of only the poor, aged, & sick isn't profitable.

Reminds me a lot of the sub-prime mortgages bindings/credit-default swaps that brought down the economy 8 years ago. Reminds me of the ride Enron took Cali electricity consumers on.

There are a *lot* of US companies that are *predators*, not friends. Whose business model is to *feed on the American people*. Unlike natural predators, however, they prefer to feed on the *healthy*.

When we had a healthy, functioning government, it *stomped* on these predators. That's the disease ... the rest is symptoms.
posted by Twang at 2:20 PM on August 17, 2016 [7 favorites]


Y'all need to read and re-read JackFlash's and cjelli's comments. Can't be bothered?

1) So this Aetna fiasco isn't representative of any failure of the ACA. It just indicates that the health insurance market is still at the mercy of your state representatives. If you had good representatives, you would have good insurance. Getting good stuff is always about getting the votes.
posted by JackFlash


2) She's saying that she'll concentrate, and that we should concentrate, on real changes we can effect now, because people are sick and hurting now, and put her political capital behind whatever can happen now. She's not saying she's against single payer, on principle, she's saying she's uninterested in debating whether or not Single Payer is, in principle, better or not because she's not interested in what's better in principle. She's interested in what's better in practice, within the scope of what can happen. Rhetorically, 'never, ever come to pass' is, pretty clearly, 'in the next four years': she was specifically responding to Sander's call for single payer during his presidency. 'Never, ever come to pass' during the next presidency is very different than literally never.

Clinton is certainly not pushing for single-payer (which I, personally, am disappointed by, but); she's pushing for a public option. But I think it's a mistake to think that that stems from an opposition to single payer in principle, or a belief that it won't happen; I think it stems from her work in the field, and her belief in what's possible in the next four years.
posted by cjelli


Yes, Obamacare was a compromise bill. The fact that it was signed into law and stands to this day is, collectively, a fucking miracle. Literally *millions* of people have access to healthcare that did not before this imperfect program was put into place. Know who didn't get those people access to healthcare? Single payer and right wing fanatics, but hey - they can bathe in their ideological purity, which didn't do jack or shit for people who needed access to healthcare at the end of the day.

Don't like Obamacare in its current form? Good - me neither. Take that dislike to the polls and vote for people who will get into office and make it better instead of bitching about it on the internet.
posted by NoRelationToLea at 2:21 PM on August 17, 2016 [8 favorites]


Don't like Obamacare in its current form? Good - me neither. Take that dislike to the polls and vote for people who will get into office and make it better instead of bitching about it on the internet.

Why do people have to choose? Maybe they're working to get progressives elected but also want to voice their criticism of the ACA. You have no right to tell them their arguments can't be heard here.

I'm a very strong proponent of the ACA, but I understand that some people believe that it further entrenches the insurance companies in the system in ways that will make it harder to untangle later. I don't find their arguments compelling, certainly not when weighed against the immense harm of not having coverage that they sometimes gloss over or stubbornly refuse to account for, but they have a right to make their case here or anywhere else.
posted by tonycpsu at 2:28 PM on August 17, 2016 [7 favorites]


~anything that ameliorates widespread suffering is to most Americans suspect specifically because it ameliorates widespread suffering.

~I understand this despair, but I think it's just not true. A lot of Americans have complicated feelings about the tradeoffs involved, but I don't think, even in our darkest timeline, that Americans have just wanted to preserve suffering for suffering's sake.


Welllll...yes and no. Many Americans fall all over themselves when it comes to feeling sympathetic toward the suffering of people they know or people they've been taught to lionize (soldiers, first-responders, clergy, elderly, etc.)

But, Americans also have an amazing ability to paint others as undeserving or even beneath them, even thought they may not know them. And, when it comes to the possibility of their tax dollars!!! being spent to assist one of those "others" to have healthcare, the outrage and spite is thick, toxic, and deep. It's utterly tribal in the most awful sense.
posted by Thorzdad at 2:58 PM on August 17, 2016 [1 favorite]


Hi there!

I'm a big proponent of the ACA ("Obamacare").

Thanks to the ACA, I was able to quit my job of 9 years, about a year and a half ago. I've started my own business, in direct competition with my former employer. I never could have done this without the ACA.

So it really is a boon to entrepeneurialism, as far as my case goes.

It is not perfect, but it is damned good.

There would be no insurer that would touch me, on either an individual or group policy, without the exclusion for "prior conditions." I've had 7 surgeries over the course of 40 years, dealing with a lifelong chronic issue.

As a newly self-employed person, with very little actual income (seriously, I am going in debt to the tune of about $1000 per month), I qualify for 100% of my insurance premium to be covered under the ACA. This is fantastic for me.

But my chronic condition is rearing its ugly head again. I'm already staring at $1500 out-of-pocket just this month. Had an expensive imaging done just this morning. I don't know what's going to happen next, but I am absolutely certain it will be expensive.

I got lucky. My insurance plan is an offering from the hospital system I'm working with. It appears to have an out-of-pocket maximum, which I will be hitting yet this month.

I could not have the life I have without the ACA.
posted by yesster at 3:21 PM on August 17, 2016 [17 favorites]


Why do people have to choose? Maybe they're working to get progressives elected but also want to voice their criticism of the ACA. You have no right to tell them their arguments can't be heard here.

Please show me where I'm saying they shouldn't be heard. I'm saying they should be heard beyond random internet comments - by voting. I'm also saying they've done very little to get healthcare access to people who need it - especially in comparison to a program they love to criticize. This ugly, imperfect monster has improved the lives of yesster and people like yesster. What have calls for single payer or misrepresentation of HRC's comments wrt single payer done for that same group of people?

It's more than a little interesting, and more than a little unfair, that you're reading that observation as an attempt to silence. You're the one concluding that ACA critics should respond to their lack of real world efficacy by silencing their criticisms, not me. Why did you conclude that?
posted by NoRelationToLea at 3:32 PM on August 17, 2016 [1 favorite]


> Answer: because she wants to build political coalitions with people who are completely opposed to single-payer ie. the AMA and/or Republicans. Same way the public-option was still-born by the Obama's desire to make a political coalition with health insurance companies... and you can see exactly how that worked out.

> the ACA left a lot of hard decisions to panels of "experts" after the bill was passed who no doubt responded to their respective sponsors... the ACA is defined by a political alliance between the Democrats and the insurance industry which basically promised magic to the various constituencies...


fwiw, before considering 'medicare for all'...
Special Deal - "The shadowy cartel of doctors that controls Medicare."
Since 1992, the AMA has summoned this same committee three times a year. It’s called the Specialty Society Relative Value Scale Update Committee (or RUC, pronounced “ruck”), and it’s probably one of the most powerful committees in America that you’ve never heard of.

The purpose of each of these triannual RUC meetings is always the same: it’s the committee members’ job to decide what Medicare should pay them and their colleagues for the medical procedures they perform. How much should radiologists get for administering an MRI? How much should cardiologists be paid for inserting a heart stent?

While these doctors always discuss the “value” of each procedure in terms of the amount of time, work, and overhead required of them to perform it, the implication of that “value” is not lost on anyone in the room: they are, essentially, haggling over what their own salaries should be.
How the AMA's Price Fixing Distorts Health Care Delivery and Pricing - "As I wrote last time, hopefully the Politico article, added to all the other attempts to shine light on the RUC, will succeed in increasing awareness of the RUC and its essential role in making the US health care system increasingly unworkable. Of course, such awareness may disturb the many people who are making so much money within the current system. But if we do nothing about the RUC, and about the ever expanding bubble of health care costs, that bubble will surely burst, and the results for patients' and the public's health will be devastating."

also btw...
  • The Long Hard Road to ColoradoCare: Amendment 69 - "What has been widely-adopted by fifty four nations as a universal government-supported health care system was first proposed by a most unlikely arch-conservative, German autocrat in 1883. Today the success of such a health care model remains irrefutable — except in the US... Canada also had no health care system for its citizens until the province of Saskatchewan stepped up in the early 1960’s and adopted their version of what the Prussians had done the century before. Once the success in Saskatchewan was evident, other provinces adopted their public health care program as Canadians took to the streets and began an impassioned, vigorous national campaign, until the government acquiesced. Voila — the Canadian Health Care System was born in 1984."
  • Health Care Industry Moves Swiftly to Stop Colorado's "Single Payer" Ballot Measure - "The campaign in Colorado to create the nation's first state-based 'single payer' health insurance system, providing universal coverage and replacing insurance premiums with higher taxes, has barely begun. But business interests in Colorado are not taking anything for granted, and many of the largest lobbying groups around the country and in the state are raising funds to defeat Amendment 69, the single-payer ballot question going before voters this November."
  • Liberal groups split on ColoradoCare universal health care measure - "A ballot measure that would provide universal health care coverage to all Coloradans has split open liberal politics in the state, with typical allies now standing on opposite sides."
oh and re: 'calvinist austerians' vs. 'enlightened progressives' (or whatever! ;)

Why Groups Fail (Hint: For the Same Reasons that Nations Fail) - "we are a dramaturgical species and the study has one great virtue that compensates for its weaknesses—the comparison of differences, including differences between students who are motivated to seek dominance vs. prestige..."
In a nutshell, students motivated by dominance (but not students motivated by prestige) sabotaged their groups when their leadership position was threatened, but not otherwise. They did this (in different versions of the experiment) by limiting the ability of the most talented group member to send messages to other group members, by isolating the most talented group member in a separate room, and by preventing the most talented group member from socially bonding with the other members. All of these tactics were clearly detrimental to the objectives of the group as a whole, abusing the student’s role as group leader.
-How Capitalism Actually Generates More Inequality
-The Economic Drivers of Political Disruption in Advanced Economies
-Tiebout Competition Leads To Crony Capitalism
-Finally, The Clearest Evidence That Shows How Money Shapes America's Elections

> There are a *lot* of US companies that are *predators*, not friends.

Virtuous Rent: a Rudder That Can Transform Our Economy - "When the appropriation of the wealth of others is illegal, it's called theft or fraud. When it's legal, it's called rent."
posted by kliuless at 3:34 PM on August 17, 2016 [14 favorites]


Please show me where I'm saying they shouldn't be heard.

___

Take that dislike to the polls and vote for people who will get into office and make it better instead of bitching about it on the internet.

make it better instead of bitching about it on the internet

instead of bitching about it

instead of
posted by Rustic Etruscan at 4:09 PM on August 17, 2016 [14 favorites]


When I hear about Aetna and their ability to make a profit, I think of that Bill Moyers interview with CIGNA exec Wendell Potter, who talked about Cigna's machinations as well as Aetna's careful, calculated shedding of less profitable health insurance customers.
posted by kristi at 5:14 PM on August 17, 2016 [2 favorites]


Speaking of Cigna, IBTimes did some great investigative reporting recently that shed light on Anthem-Cigna merger shenanigans in the state of Connecticut.
When Anthem’s plan to acquire Cigna was being negotiated in early 2015, Connecticut’s Democratic Gov. Dannel Malloy appointed Katharine Wade as his state’s insurance commissioner: She was a longtime Cigna lobbyist whose father-in-law works at a law firm that lobbies for the company, whose mother and brother previously worked at Cigna, and whose husband still does. She was also a top official of the major lobbying group for the state’s health insurance industry. As commissioner, she appointed a top deputy who worked at Cigna and she had a former longtime Cigna employee serve as an agency counsel in the merger review. As Wade continues to oversee Connecticut’s review of Cigna’s merger, she recently secured a position chairing a healthcare policy committee for insurance commissioners across the country. Malloy’s decision to appoint Wade to such a powerful regulatory post on the eve of the merger was not made in a vacuum. It came after employees of Cigna, its lobbying firm Robinson & Cole and Anthem delivered more than $1.3 million to national and state political groups affiliated with Malloy, including the Democratic Governors Association (DGA), the Connecticut Democratic Party, Malloy’s own gubernatorial campaign and a political action committee supporting Connecticut Democrats.
posted by kyp at 5:29 PM on August 17, 2016 [3 favorites]


Aetna's careful, calculated shedding of less profitable health insurance customers.

What Obamacare did was eliminate Aetna's old business model of discrimination and obfuscation as a means of keeping only above average healthy customers. Now insurers have to accept all customers. The ACA exchanges have made competitive comparison shopping much easier. Aetna has demonstrated that they are business failures that cannot adapt to the new competitive markets. Badly run businesses are supposed to fail and Aetna's failure is an indication that markets are working as they are supposed to. Smarter, more nimble insurers will take their place.

Aetna's attempt to merge with Humana was just a last ditch effort to avoid their inability to compete by creating a non-competitive monopoly. Good on the Obama administration for resisting this.

I see the failure of Aetna as a sign of good progress on the bumpy road to the new ACA insurance market. We are only two years into this new market and it will probably take a few more until it all settles down. Until we have national health insurance this is a much healthier private insurance market than previously.
posted by JackFlash at 5:46 PM on August 17, 2016 [7 favorites]


Aetna or no Aetna, the exchanges need help - "The latest carrier withdrawal deserves scrutiny, but it also reminds us that the marketplaces face real challenges that require adjustments." (via)
posted by kliuless at 6:24 PM on August 17, 2016


ACA critics feel silenced because the desire to continue to criticize the program is rightfully seen as incredibly petty and wrong-headed when confronted with the fact that this second rate, wrong choice, it'll never work, corporate compromise program has so far resulted in 20 million fewer uninsured Americans and an all-time low uninsured rate.

I completely understand why the right wing is against this program. What I don't understand is why the alleged progressive left would rather pout about how they didn't get their single payer pony vs. working to improve a program that even in it's current imperfect form probably represents the single biggest improvement to health care access we'll see in our lifetimes. Beyond pouting coming from being way down on the total number of people helped scorecard, I mean.

You know what? Y'all are right. Fuck those 20 million people. Let's start over.
posted by NoRelationToLea at 6:39 PM on August 17, 2016 [3 favorites]


The problem for single-payer advocates is that you are effectively arguing that the problems with the US healthcare industry are problems of economic demand:

1) there isn't enough demand for healthcare because lots of people can't afford it

2) pricing is inefficient ie. too high because of the way payments in the health care industry work.

But there are huge *structural* problems with the supply of health-care in the US ranging from how big pharma is "regulated" to the supply of doctors, the distribution of doctors geographically, and so on.


I am curious: I assume "distribution of doctors geographically" is referring to the way rural communities are underserved?

Thing is, that problem is mostly bound up in point number one: these people need healthcare, but don't have the money to be considered a "market". Bringing in an outside source to pay for their healthcare makes them suddenly a market.

also as other people said: Most people when they say "single-payer" actually mean "like they have in Canada and Britain." They don't mean that single-payer is the be-all-end-all complete solution. If you tell them that the supply of doctors is throttled by the AMA and medical universities - which it is - they'd be entirely fine with the government taking steps to change that.
posted by Rainbo Vagrant at 7:21 PM on August 17, 2016 [4 favorites]


You know what? Y'all are right. Fuck those 20 million people. Let's start over.

Yes, fuck all 20 million of those people in need, this is definitely a good-faith representation of the desires of the ACA's left-wing critics.
posted by Rustic Etruscan at 8:00 PM on August 17, 2016 [14 favorites]


You know what? Y'all are right. Fuck those 20 million people. Let's start over.

Well, the ACA has cut the number of uninsured Americans in half, so fuck those OTHER 20 million people; we've done enough.
posted by oneswellfoop at 8:06 PM on August 17, 2016 [4 favorites]


Yes, fuck all 20 million of those people in need, this is definitely a good-faith representation of the desires of the ACA's left-wing critics.

This is no less a good faith read than what you've extended to me, so far.

Sorry, let me quote someone else in this thread - "Burn it all down." Do we in the critical left like that phrasing better?

Well, the ACA has cut the number of uninsured Americans in half, so fuck those OTHER 20 million people; we've done enough.

You said that, not me. I said "working to improve a program that even in it's current imperfect form..." But, hey given the good faith readings we're affording each other in this thread, I can totally see how that could be read as fuck those OTHER 20 million people, instead.
posted by NoRelationToLea at 8:14 PM on August 17, 2016 [1 favorite]


I completely understand why the right wing is against this program. What I don't understand is why the alleged progressive left would rather pout about how they didn't get their single payer pony vs. working to improve a program that even in it's current imperfect form probably represents the single biggest improvement to health care access we'll see in our lifetimes. Beyond pouting coming from being way down on the total number of people helped scorecard, I mean.

Nobody I've ever read who is saying the ACA needs to be made better is simultaneously arguing that we should scrap what we have and start over.
posted by Ray Walston, Luck Dragon at 9:02 PM on August 17, 2016 [6 favorites]


Where is the evidence that, specifically in healthcare, Americans don't support a single payer option that provides healthcare for their fellow citizens?

Every recent poll I've seen indicates that Americans overwhelmingly support a universal option.


Here for example, from Gallup earlier this year. If you ask Americans if they prefer public vs. private health care they choose private by around 15 points. Even the simple question as to whether it is the responsibility of government to ensure health care is tied, within the margin of error.

This also from Gallup shows support for "federally funded universal health care," so you can make the argument that there's some evidence it'd fly. I don't think it's politically meaningful, because (1) it's a generic plan with no specifics to oppose or no cost, (2) majorities admit they don't know enough about what that means when given the option to choose that answer, and (3) this includes a large plurality of Republicans saying they want single payer over ACA. The last point IMNSHO is particularly telling--that Republican support goes to like zero percent the second a Democratic president actually proposes more government control of health care.
posted by mark k at 10:08 PM on August 17, 2016


Speaking as a Canadian, I don't think there's anything I find more unsettling about life in the United States than its health care model. On Tuesday night I started having severe abdominal pain. When it got so bad I started hyperventilating, my wife called 911 and I was taken to a hospital emergency room where I spent the night being attended to by several doctors and nurses, being given painkillers and antibiotics and undergoing a CT scan before being diagnosed with an abdominal infection. Total cost to me: the taxes I happily pay (I am extremely fortunate to have private employer-funded insurance that covers the cost of my medications).

This is not to say the Canadian model is perfect, because it most assuredly is not, but the idea that my wife and I might have had to weigh how much pain I was in against how much getting it treated would cost is horrifying to me.
posted by The Card Cheat at 12:02 AM on August 18, 2016 [11 favorites]


Here for example, from Gallup earlier this year[...]

I was challenging You Can't Tip a Buick's assertion that Americans innately have no compassion for their fellow citizens, so I'm not sure if the public versus private question is relevant here. I guess you could make an argument that preferring private healthcare signals that somehow, but that seems tenuous.

As for the question that shows that the majority of Americans favor single payer over ACA, the poll also shows that a (small) majority also prefer keeping ACA in place. To me, that demonstrates that Americans (including Republicans) are more interested in preserving ACA and expanding healthcare than not.
posted by kyp at 12:12 AM on August 18, 2016


I am very dissatisfied with the ACA as it currently stands.

That is not the same thing as saying I want to throw it away before we have something better, and I'm pretty tired of people pretending that's what I'm saying.
posted by Foosnark at 5:53 AM on August 18, 2016 [4 favorites]


What a bunch of crooks! I really hope Colorado pulls through. Looking at how the rest of the world got to universal healthcare through long, contested processes, I think the first wave of change has to happen at the state level. See also marihuana and LGBT rights.
posted by mumimor at 7:18 AM on August 18, 2016


When the people supposedly in favor of universal health care only ever talk about the ACA to call it a garbage worse-for-me-now giveaway to health insurance companies... why exactly is it confusing that that looks like "throw it away" to those of us who are thrilled to have gotten it and now want to improve it?
posted by phearlez at 11:08 AM on August 18, 2016 [1 favorite]


As for the question that shows that the majority of Americans favor single payer over ACA, the poll also shows that a (small) majority also prefer keeping ACA in place. To me, that demonstrates that Americans (including Republicans) are more interested in preserving ACA and expanding healthcare than not.

The majority of Americans really couldn't give a 15-second definition of what ACA or single-payer or public option or insurance exchange means, let alone have an educated opinion of how the system works and how changes to the medical insurance system would affect delivery of care.

Which is itself a big part of the problem. People are used to having to give chunks of cash at various times to various entities and then all that money sort of gets mixed up in this big black box and eventually out pops "medical care". Sort of. Maybe. Or maybe you have to pay more on the spot at the doctor's office because you put the money in the wrong place or that card you got at one point has the wrong logo on it or you don't know but you're really annoyed because no one seems to be able to figure out exactly what the problem is and what you can do / should be doing / should have done about it

and we haven't even gotten to dental yet

So it's not too surprising that people's responses to WHAT DO WE DO ABOUT HEALTH CARE fall roughly into three buckets: (a) destroy with fire, rebuild from the rubble; (b) CHANGE NOTHING as I finally have a halfway decent handle on how to get care in my current situation; (c) DO THIS THING that a politician I trust said will fix everything.

It's not really people's fault that they're expected to understand a system that no one in the entire country is capable of comprehending in its entirety.

That being said, I do think single-payer (on a state-by-state basis) is probably the best way forward, starting hopefully with Colorado if their referendum passes in November. I like the idea Hillary's incremental expansion of Medicare (by lowering the eligibility age to 55) in some ways but I also think that Medicare is still much more complex than a broad-based insurance scheme needs to be. I should go look at the details on her site again though, I think it's been updated recently.
posted by tivalasvegas at 11:11 AM on August 18, 2016 [2 favorites]


This is not to say the Canadian model is perfect, because it most assuredly is not, but the idea that my wife and I might have had to weigh how much pain I was in against how much getting it treated would cost is horrifying to me.

Yes. I can explain the gist of your system very easily.

1) You pay a progressive income tax that gets automatically taken out of your paycheque
2) You go to a government office, show proof of residency and get a photo ID health card
3) You go to a doctor or hospital when you need medical care, show your health card and get care

So all the idiots who say it doesn't can't never won't impossible to work are, well, idiots.

Getting to there from here, that's the difficult part.
posted by tivalasvegas at 11:21 AM on August 18, 2016 [2 favorites]


Cross-posting a bit from the new post on Merck's Gardasil ad

AMA Calls for Ban on Direct to Consumer Advertising of Prescription Drugs and Medical Devices (November 17, 2015)
Responding to the billions of advertising dollars being spent to promote prescription products, physicians at the Interim Meeting of the American Medical Association (AMA) today adopted new policy aimed at driving solutions to make prescription drugs more affordable.

Physicians cited concerns that a growing proliferation of ads is driving demand for expensive treatments despite the clinical effectiveness of less costly alternatives.
posted by filthy light thief at 12:02 PM on August 18, 2016 [2 favorites]


"The United States and New Zealand are the only two countries in the world that allow direct-to-consumer advertising of prescription drugs. Advertising dollars spent by drug makers have increased by 30 percent in the last two years to $4.5 billion, according to the market research firm Kantar Media."

That's $14 for every adult and child in the US. Ridiculous. (Not even counting the added costs from people who go beg their doctor for medically unnecessary or more expensive rx because of the ads.)
posted by tivalasvegas at 12:05 PM on August 18, 2016 [3 favorites]


Yup, I agree wholeheartedly.

Annoying news coverage of this, from the "business side" - whatever NPR's embedded before-the-hour business report had a bit on this Aetna mini-scandal, identifying the apparent blackmail without calling it blackmail, then noted "under the ACA, Aetna did face profit losses," without stating 1) how much, or 2) what the earnings looked like compared to prior years, and 3) if there were any grounds to the claim that Aetna would not be profitable without a merger like this one.

At which I shouted "ACA WAS NOT TO BOLSTER MEDICAL INSURANCE COMPANY PROFITS! IT WAS FOR MORE AFFORDABLE CARE!"
posted by filthy light thief at 12:14 PM on August 18, 2016 [8 favorites]


Wow, you're surprisingly articulate when you yell at the radio. I don't come off nearly that well.
posted by tivalasvegas at 12:30 PM on August 18, 2016 [2 favorites]


That is not the same thing as saying I want to throw it away before we have something better, and I'm pretty tired of people pretending that's what I'm saying.

This exact bit of semantic parsing came up last fall. Sanders was accused of wanting to dismantle the ACA. He responded by saying he wanted to expand it. So which is it?

Sanders has said repeatedly that he wants to build on the health-care system created under the Affordable Care Act and to expand it to provide health insurance regardless of income or age. It’s clear that the provision in his bill to “repeal” ACA state exchanges was not just for the sake of repealing the law, in the way critics who oppose passage of ACA use the term “repeal.”

But the language of his legislation — all three times he introduced it — clearly stated that existing federal programs would be replaced with a new program that he sought to create. It wouldn’t simply increase current levels of coverage but would create a whole new health insurance system with new quality-control methods, a new standards board, and more.

We wavered between Two and Three Pinocchios. Sanders makes it sound as if he would tack on some additional provisions or coverage to ACA — when, in reality, his new single-payer health system would replace the ACA and all other existing federal coverage.


Sure. ACA critics don't use my phrasing of "Fuck those 20 million people." But by arguing for single payer (which Sanders submitted then withdrew in 2009, and submitted again in 2011 and 2013 - neither time went to a vote) the net effect is a branding or tone argument. Pursuing that option during the prevailing congressional conditions at any of those times (or now) ends up with nothing - therefore fucking those 20 million people. Maybe that wasn't the critics' intent - but who bares the responsibility of that failure? ACA critics get a free pass there?

ennui.bz has a very astute comment up thread that starts with "The problem for single-payer advocates is that you are effectively arguing that the problems with the US healthcare industry are problems of economic demand..." They're absolutely right in saying there's a structural issue that the ACA doesn't address at all. So what do we do about it?

...the only way to solve this is for the government to directly intervene by changing the way drugs are funded, the way doctors are educated, and to build hospitals and clinics.

The ACA barely passed, and is regularly challenged in the legal system. A bill that nationalizes just drug funding, or just medical education, or just how hospitals are built or funded wouldn't have a hope in hell of passing in West Wing fan fiction, much less the congressional conditions of the last 10 years, or likely the next 10 years. I agree that some combination of that stuff is probably what should happen. You probably agree that unicorns are magic and rainbows are pretty. All of that agreement results in, again, fucking those 20 million previously uninsured Americans. Not my fault, man - I wanted to provide care to everybody.

Woulda, shoulda, coulda - we should have tried for more. We did try for more. 20 years ago during Bill Clinton's first term. Know what we got then, with Democrats in control of the presidency, the house, and the senate? Nothing. How much further along would we be now had the ACA's incremental, foot in the door approach been tried then?
posted by NoRelationToLea at 1:13 PM on August 18, 2016 [2 favorites]


Thankfully, Sanders has evolved on his stance on ACA:

Sanders revs up ‘public option’ fight after Aetna leaves ObamaCare
Sen. Bernie Sanders (I-Vt.) and other healthcare reform advocates are revving up their push for a “public option” after Aetna’s retreat from the ObamaCare marketplace this week.

Sanders on Tuesday vowed to bring back the debate on a government-run insurance option one day after the nation’s third-largest insurer announced a major pullback from the exchanges.

The senator said he would reintroduce his legislation to create a “Medicare-for-all” system in the next session of the Senate, “hopefully” after Democrats regain control of the chamber in the November elections.

“In my view, the provision of health care cannot continue to be dependent upon the whims and market projections of large private insurance companies whose only goal is to make as much profit as possible,” Sanders said in a statement on Tuesday.

“That is why we need to join every other major country on earth and guarantee health care to all as a right, not a privilege,” he said.
posted by kyp at 1:34 PM on August 18, 2016 [2 favorites]


Hang on, I just looked at that NYT article posted upthread about Clinton's support for a 'public option' by which she means giving people between the ages of 55 and 65 the option to keep their private insurance or take Medicare.

How would that not lead to a death spiral that takes down the whole Medicare system?
posted by tivalasvegas at 2:05 PM on August 18, 2016 [4 favorites]


How would that not lead to a death spiral that takes down the whole Medicare system?

What Is Hillary Clinton’s Agenda?
A public option could come in different forms. One possibility endorsed by Clinton is a Medicare buy-in for people when they reach age 50 or 55. This is not a new idea; Bill Clinton proposed it for 55- to 64-year-olds in the late 1990s and Al Gore supported it in his 2000 presidential campaign. The difficulty then was the likely cost resulting from “adverse selection”; the people most likely to enroll would have been those in poor health with high medical costs. Although this problem won’t have disappeared, it should be more manageable because of the subsidized plans already available in the insurance marketplaces. In fact, by taking 50- or 55- to 64-year-olds out of the general risk pool, a Medicare buy-in could result in lower premiums (and therefore lower federal tax subsidies) for everyone else in the insurance marketplaces. Letting Medicare compete for middle-aged enrollees in the insurance exchanges could be an incremental step toward a general public option.
That's the idea, anyway -- that the ACA as it exists has already committed to covering more of these people, so why not get more of them into the closest thing we have to a single-payer system. The government pays the bill either way via ACA subsidy or the cost of Medicare, so why not do it through what should be the more efficient program.

I'm not entirely convinced that this logic will work in practice, and would love to see some research that supports it, but it's at least a plausible explanation.
posted by tonycpsu at 2:26 PM on August 18, 2016 [3 favorites]


And here's a timely blog post from Richard Mayhew at Balloon Juice that works through some of the possible negative consequences of the public option:
There are scenarios where a public option could make the current risk pool worse off.

[...]

In some regions there is currently a decent size gap between the #1 Silver premium and the #2 Silver. That gap allows for lower income individuals to pay significantly less out of pocket for either the #1 Silver or quite a few Bronze policies than people with the same income in regions where there is only a $1 gap between the #1 and #2 Silvers.

Now let’s insert a Public Option with Medicare like rates into the mixture. In regions where there is active Silver Spamming going on most of the plans are empirically being priced out at near Medicare rates anyways. Nothing will change. In some regions where there is a large gap between the #1 and #2 Silvers, the public option would either be the new #1 (unlikely in the linked version as that pricing is Medicaid driven) or more likely be the new #2 Silver. If it is the new #2 Silver, that means the gap between the current #1 and the new #2 is less than the gap between the current #1 and the previous #2. If that is the case, then subsidized individuals who were marginally attached to buying health insurance would drop their coverage. Those individuals are far more likely to be very healthy as their value proposition for insurance is very different than the person who has weekly doctor appointments and a dozen prescriptions.

Moving off-exchange but still on the Individual Market, the Public Option would improve the risk pool only if it is both significantly less expensive in full price premium and offering a significantly better value (network mainly) than any other current option. In some cases that could be true but it would not be a universal case.
posted by tonycpsu at 3:10 PM on August 18, 2016


yeah I'm still mentally turning this over in my head. (I guess that's the only place you can mentally turn things over, on second thought.)
posted by tivalasvegas at 3:33 PM on August 18, 2016


Richard Mayhew, I think, is making it overly complicated -- true in a theoretical sense but less important in reality.

First off, the risk pools are just fine. As the most recent CMS report indicates the average medical cost per enrollee has stabilized and in many states average medical costs are decreasing. This indicates that low medical cost healthy people are signing up in significant numbers.

As an aside, it probably is necessary to remind people that what insurance companies really want are healthy old people, not the mythical healthy young invincibles. That is because, according to the ACA community rating rules, insurers charge three times the premium for a 60-year-old as for a 25-year-old. Healthy old people are the holy grail. Fortunately these elderly are more likely to sign up for insurance because they have more assets to lose if they have a medical emergency.

Anyway, the Richard Mayhew analysis assumes that people will leave the risk pool if there is a public option. That just doesn't seem to be the case. The way each insurance company handles this is by providing a wide range of price/benefit options in various plans. Healthier people will choose the low cost/low benefit options and sicker people will choose the higher cost/higher benefit options. True, there is adverse selection segregating across the plans.

But here is the important point. A good insurance company attracts customers all across the risk pool from high to low by offering a range of plans. The ACA penalties ensure that there is a high participation rate from the entire pool and the CMS report above confirms that.

The problem Aetna had is that is was not positioned to offer a wide range of plans. Previously it offered relatively high benefit but low cost plans because it discriminated to only enroll healthy people. Under the ACA they then offered these same high benefit plans but also had to enroll sicker people. They lost money. They failed to offer the broad range of offerings that would give them a diverse risk pool. They screwed up. Their mistake was their own, not the ACA. They failed to offer the lower cost/lower benefit plans that would attract a larger portion of healthy people. The risk pool is fine. Aetna just failed to recruit the more profitable customers.

As for what would happen if we had a public option, we already have an example in the Medicare system. Traditional Medicare is the public option and Medicare Advantage is the private insurance option. The public option has better benefits, having essentially an unlimited provider network. It makes up for some of this by having about 20% lower overhead costs than private insurers. But still the premiums for the public option are somewhat higher than the private option, but with a wider network.

The private insurer Medicare Advantage option competes by only having a very narrow HMO provider. So their medical costs are lower, but their overhead costs are higher than the public option. But overall, their premiums are lower than the public option. The market sorts this out as customers decide whether they want a lower premium/smaller network (private insurance) or a higher permium/wider network (public option).

I would expect the same thing to happen in the exchange if a public option were added. The public option would dominate among those who want a wide network. Almost all of the private plans would end up being lower premium narrow HMOs.

But the bottom line is that the risk pools are fine. Aetna simply failed to compete. And with a public option the ACA exchanges would be fine, but likely much simplified as the market would, like Medicare, have a dominant public insurance and a small number of private HMOs.
posted by JackFlash at 5:00 PM on August 18, 2016 [4 favorites]




How would that not lead to a death spiral that takes down the whole Medicare system?

If you think of Medicare as a shift from rationing to an all-you-can-eat-buffet, it might actually be more useful to have people enter the system at 55 when certain conditions are less advanced and more treatable than at 65, but there's not the same incentive to undergo screening or other early-stage treatment within the private insurance system.

Medicare's messy. T.R. Reid covered this years ago. It's exploited far too much, as some of the shitshow stories from Florida make clear, precisely because it's treated as a kind of gift granted to seniors.

Richard Mayhew is a really useful resource, but I think he's often tied to status quo bias by his position within the insurance industry, particularly when he assumes that many of the complexities of the current system must somehow be perpetuated. It shouldn't be this fucking hard, either for insurers or the general public.

The core point here is that Aetna is a shitshow of an insurer that is not fit for purpose, and only survives because what Americans (still!) have instead of a healthcare system is a shitshow. Big big pools, tariff negotiation with providers, incentives to hold down prices: that's the stuff that works.
posted by holgate at 11:33 PM on August 18, 2016 [2 favorites]


Joining the choir of fuck Aetna. Just had my second child and they are sure to be fighting to not pay for things tooth and nail. Having a child, while insured no less, should not be accompanied by fear of financial punishment.
posted by RolandOfEld at 6:29 AM on August 20, 2016


"States with strong, populist commissioners like California and Washington have very robust, highly competitive insurance markets with dozens of options. States like Georgia or Tennessee with industry toadies for insurance commissioner -- well it sucks to be you as a health insurance customer."

I am about to move from Seattle to Atlanta. How screwed am I?

(What's worse -- I am on Medicaid at the moment.)
posted by litlnemo at 6:52 PM on August 21, 2016


I am about to move from Seattle to Atlanta. How screwed am I?

(What's worse -- I am on Medicaid at the moment.)


Your problem is that the state government of Georgia did not opt to expand Medicaid to (most) residents whose income is below 138% of the federal poverty line, following a US Supreme Court decision that states were indeed able to decide for themselves whether they would comply with the Affordable Care Act on this point.

So you probably won't be able to get health insurance that you'll be able to afford, unless you're moving to take a different job that offers insurance or at least that changes your income. If your gross income is over 100% of the poverty line (about $1000 per month, if you're not married and don't have any children that you claim on taxes), you might be able to get subsidies through the ACA exchange (healthcare.gov). Otherwise you'll have to pay for a private insurance plan without any help with your premiums.

Feel free to MeMail me if you have further questions.
posted by tivalasvegas at 7:55 PM on August 21, 2016 [2 favorites]


Yeah, I did know that much, which is why I mentioned Medicaid. :/ I'm just hoping my income will be high enough to put me over the poverty line. (I don't have a job lined up yet. I will be living on savings for a while. And I am on regular meds that I really need to take under medical supervision. As a female in my 50s with some current medical issues to deal with the job market has not been friendly to me lately. I've had the lucky opportunity to be able to sell a Seattle home now, and therefore will finally have some decent savings to draw from, but that won't last me long enough to reach Medicare age.)

I don't usually swear like this on MeFi, but FUCK the Georgia state government. And the state governments of all other states who have done this sort of thing.

Also, FUCK Aetna. Here's an Aetna story I was going to post earlier but forgot.

Years ago I was working as a temp and got a job for a couple of days at an Aetna office. Just filing and stuff. Mid-late '80s. I was bored and no one was really paying attention to me, so I peeked at some of the paperwork I was filing. One was an insurance claim file for someone. There was a note attached that said, basically, "she has a valid claim but she doesn't really know that and she won't fight for it -- turn her down." I was shocked to see it in writing. Aetna will never get a penny from me if I have any say in the matter.
posted by litlnemo at 12:11 AM on August 22, 2016 [2 favorites]




gladly, is this the Vox link you were shooting for?
posted by tonycpsu at 9:18 AM on August 24, 2016 [1 favorite]


Blergh -- yes, that's close to what I was aiming for. This is the animated map showing the reduced competition between 2016 and what's forecast in 2017.
posted by gladly at 12:33 PM on August 24, 2016


An American doctor experiences the NHS. Again.
"Dear U.K., the NHS is awesome. Try to treat it a little better. Maybe teach kids in school how to use the health care system (hey, why not NHS ed alongside drivers ed or sex ed?). Have safe sex. Stop smoking. Try to lose weight if you need to (obesity causes 30% of cancers). Wear lower heels for dancing. And for crying out loud stop stealing wheelchairs. The next time anyone mentions privatization or user fees tell them in America there are people trying to save enough money for the copayment for the CT scan that will tell them if their cancer has returned or not."
posted by kliuless at 2:22 PM on August 24, 2016 [3 favorites]


gladly, is this the Vox link you were shooting for?

The "Medicaid-ization" of Obamacare
The marketplaces' failures to attract a robust group of health plans to many areas suggests that Obamacare’s insurance expansion is on the path to looking like other safety net programs we know, offering limited services to a predominantly low-income population.

"The exchange population — 85 percent of which qualifies for financial assistance — looks a lot like the Medicaid population," says Michael Adelberg, who previously served as the administration’s acting director of the exchange policy. "And with it, we’re seeing the start of the ‘Medicaid-ization’ of exchange plans: narrow networks with no frills."

[...]

There are areas of the country that had competitive individual markets prior to Obamacare, largely places that are urban with affluent populations. Those places tend to continue to see multiple plans offer coverage. But in the areas that have long struggled to attract competition — places with smaller, low-income populations — the situation has not hugely improved.

The problem is getting worse... the marketplace is now much smaller than expected. There were 12.7 million enrollees this year — 8.3 million less than the Congressional Budget Office projected in 2015. A smaller marketplace is a less compelling place for insurers to invest in — and that, in turn, makes it a place that companies are less likely to send their workers.
Public option? Status quo? Collapse? What comes next for Obamacare.
"If you end up with places in the country where literally no one wants to sell, then you really need an intervention — and the public option seems like the cleanest one. But if we end up in a world where the administration can cajole at least one carrier into each market, then we might end up in your second scenario, where the marketplace is where you buy narrow-network plans that have high deductibles and copays. And this would be something of a departure from what architects envisioned for the choice the markets would offer. It would mean that the people who get coverage through their jobs have significantly better health insurance than those who buy on the marketplaces."
posted by kliuless at 4:26 PM on August 24, 2016


" It would mean that the people who get coverage through their jobs have significantly better health insurance than those who buy on the marketplaces."

This is the endgame for the capitalists, of course. The entire point of the health insurance system is to increase capital's leverage on the workers. "You want a raise? If you protest too much, your kids don't get to see a doctor. You'll work longer and for less money, or we'll let your family die."
posted by vibrotronica at 8:39 AM on August 25, 2016 [2 favorites]


This is a serious question, but, wasn't this always the plan? The exchange healthcare was for people who were super sick or poor and couldn't afford better plans or didn't have good plans through their work? I never heard anything about exchange plans trying to be competitive, benefits wise, with employer plans. Were there exchange plans that were better for less money than than the really good employer plans?
posted by corb at 10:35 AM on August 25, 2016


This is a serious question, but, wasn't this always the plan?

I think the initial belief was that the opposite might happen: that smaller businesses would give up their group plans (and save on the HR/admin overhead required to run them) and get employees to use the exchanges instead, usually with a raise in take-home pay to cover what was going into their premiums behind the scenes. That would have created larger and broader risk pools. There was actually some worry that too many firms might do that all at once, which would make actuarial modelling a bit harder, and you might remember the discussion about whether employers would cut employee time below 35 hrs/week to avoid an employer mandate.

Small group plans are a volatile area: imagine a business with 20 employees, and one has a serious illness or develops a chronic conditions, or simply hires a couple of women who are at an age where there's a good chance they'll get pregnant: that can make the annual reassessment with the insurer pretty rough.

Were there exchange plans that were better for less money than than the really good employer plans?

It's not an easy comparison. Employer plans don't always make clear how much is being diverted to a premium; you can extrapolate it somewhat from spouse/family premium add-ons, but anecdotally the Gold/Platinum exchange policies aren't massively different from a large group plan with a very diverse pool of employees.
posted by holgate at 3:42 PM on August 25, 2016 [3 favorites]


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