Sunday, March 25, 2012

Sunday Question for Liberals

Suppose that SCOTUS rules for ACA, ending the legal challenges to the law. What does the health care system look like in the US in another decade? Are the exchanges working and relatively noncontroversial? Was cost control somewhat successful? Do Republicans remain rejectionist, and eventually repeal it when they get the chance? Or does the system break down in some other way, and if so is the next step predictable from here?


  1. this is an easy one. technology advances to the point where we can buy a $39.99 iPhone app that heals all medical problems with alpha waves. that, along with other technological advances that make scarcity of food, space and entertainment obsolete, eventually relegates our political class to arguing exclusively about what historical events and people our society should commemorate and how.

  2. Health insurance companies are the new oil companies, obscenely wealthy as a result of their guaranteed customers and guaranteed profit. Health costs still soaring.

    (Note: I am a liberal and I think something has to be done, but the ACA is a recipe for disaster.)

    1. Only difference being that oil companies actually produce a tangible product. With both underwriting and risk eliminated under the ACA, the only function of health insurance companies will be to push paper and collect $$$.

    2. You’re forgetting that there aren’t huge profit margins in selling insurance—insurance is expensive because medical care in the US is expensive (and providing health care is far more profitable than selling health insurance). One of the big reasons it’s hard to bring down health care costs is because it’s impossible to do so without judging medical procedures and practices based cost-effectiveness (witness the controversy over IPAB).

    3. Profit for insurance companies is built into the ACA structure. The whole thing falls apart if they lose money (since they are doing the job that a single payer should be doing). So the profits might be small but they are guaranteed. In the long run, no risk profits are a license to print money.

    4. Insurance companies don't make profits, they make investments.

  3. I believe that as the law is implemented, and does so properly, the GOP will calm down about it, especially since the Supreme Court will take out their strongest argument against it. After all, once health insurance becomes cheaper and more accessible, Democrats will be able to say that ANYBODY who has health insurance could lose it, not just the then-insignificant uninsured people.

    The Democrats could say, "The GOP wants you uninsured." And the lack of good info on the law could work in their favor. That obviously won't stop the GOP, but it will be harder to repeal a law that is set up than one that abstractly attacks ideology. And since it is not by age or race, you cannot try to start a battle between them, like Ryan tried on Medicare.

    Bill Kristol said that universal healthcare would destroy the conservative movement. I wouldn't say that, but it would weaken it in the long term.

  4. While I consider myself liberal, I think that conservative ideology does teach something to learn from here. A couple of reasons that healthcare costs are skyrocketing are malpractice insurance and regulation of health insurance. The malpractice comes in two ways: 1) doctors need to pass on higher costs of doing business, and 2) doctors order a lot of unneccesary tests (which are quite expensive). Since we don't pay for that directly (only indirectly through higher premiums paid partially from our paychecks and partially from our employers, which also makes the costs hard to notice), we don't object to paying these costs. So, we incur more of them, costing everyone.

    Secondly, think about all the paperwork that happens in health. It's staggering. And a lot of that paperwork either comes from insurance companies forcing it on themselves and others to lower payments (either by denying care or making it easier to not get care) or by regulations forcing the health care industry to comply.

    Now, so far, this all sounds like a purely conservative response to the question. But, I'm actually liberal and actually think that the whole thing will work out, eventually. Here's how: ACA couldn't possibly fix these problems. So, I think that, in a decade, health care cost growth will have only slightly attenuated. Exchanges will be afterthoughts. Cost control will NOT have worked. And so, my hope is that, at that point, people will realize that the ACA, which is fundamentally a CONSERVATIVE health care fix (they've been pushing the mandate/insurance model as their fix for 30+ years now) just ain't going to cut it. My hope is that we'll also be at a point where the demographics are cutting so hard against the GOP (read: more Latino voters) but the GOP hasn't yet pivoted to the center that the Dems will have SOLID majorities and the ability to implement a REAL fix: single payer.

    So, while optimistic, it's in the longer term, once this BandAid of a solution falls apart.

  5. Wow, that’s like the most complicated policy based wonky Sunday question yet! Seriously, I think that conservatives are ideologically opposed to the idea that all Americans should have access to health care, but they’ve shown remarkable flexibility on the policy front. None other than George W Bush whined on national television that “you can always go to the emergency room” when asked about the tens of millions of Americans without health insurance. Remember the basics of the dreaded Obamacare law as a policy solution to tens of millions of Americans not having health care was literally developed in right wing think tanks and endorsed by conservative leaders in politics throughout the 90’s.

    That said, I think the GOP will always try to destroy “Obamacare” but not necessarily to its effects. GOP state legislatures may throw fits about the Obama planned unthinkable horror of people being allowed to shop and compare health plans on an internet site, but I doubt they will make such shopping illegal. But that’s not necessarily “Obamacare”, even if it is a main point of the law. I suspect that some future GOP presidential candidate in 2016 or whenever will say something to the tune of “We need to repeal Obamacare and stop these ACORN people and young people from being freeloaders and not having health insurance and getting emergency room access every day!”

    Mitt Romney says these types of ridiculous things every day.

  6. Within a decade, single-payer. And, if the Supremes throw the whole law out, within 20 years, single payer. There's no other way to control the costs without a health care catastrophe for the poor and, plausibly, many middle-class families as well.

  7. Agree with @doc. Companies will drop their health plans, and practically everyone will be thrown onto the exchanges. Spiraling health care costs will do the rest.

    (Regarding US health care costs, there is one reason that no one ever mentions why they are so high: We are a nation of hypochondriacs. Offer a quack cure and we will line up to pay for it. After all, we are the people who invented 'snake oil.')

  8. Hmm 10 years, that's 2022. The free market of the 1950s was not the same as the free market of the 2010s. Health care cannot be separated from the rest of the economy. If we have the same free market in 10 years as we do now. No system is gonna work. If there are sensible reforms in other places in the economy, then obamacare will probably be seen generally as a good thing.

    The usual conservative suspects and their young acolytes will NEVER stop grumbling about it. To what extent the republican party will reflect those views is open to speculation.

  9. Got me...does it matter what anyone thinks if SCOTUS supports it now? After 10 years of the good, bad and ugly of ACA, it's still better than having all those people unable to get insurance.

  10. Within a decade, nothing.

    ACA is repealed legislatively within the decade, once the GOP have majorites to do it with.

    Replaced by nothing except tort limits and a few other nostrums.

    The uninsured grow to 40-45% of the population.

    Pray there are no pandemics.

  11. Vermont is trying to pioneer single payer starting either in 2014 or 2017, depending on how Obamacare allows it. That and possibly one or two other states will be an experiment that will slowly spread if it seems to work. I think it'll work, but what I think doesn't matter, we'll see the effect when it happens.

  12. I think the mandate is going to fantastically unpopular, and is likely to be repealed/replaced with other options (limited enrollment period, etc). If that makes the law fall apart, then it will fall apart and the effort will be seen as a somewhat ignominious example of liberal overreach. but if not, it will make things a little better over time, but won't make people feel that much better about the health care situation over time, and will merely be seen as a somewhat ineffective reform that nevertheless had some good effects (covered most of the uninsured, ended pre-existing condition denials).

    And yes, I am a liberal and was for comprehensive HCR, though for other options than the mandate to solve the adverse selection problem, because the mandate is political poison.


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