Did Obamacare succeed in creating the expectation of universal health care?
Charles Krauthammer thinks it did:
On Friday’s edition of ‘Special Report’ on Fox News Channel, syndicated columnist Charles Krauthammer made the case that President Obama’s strategy for Obamacare was not to create a perfect health care system, but to create the expectation that health care is something the government is responsible for. He said Obama had been successful at “creating the expectation of universal care” and that as a result “the zeitgeist of the country has really changed.”…
“That is the logic of Obamacare. It was a jerry-rigged system which would temporarily create an entitlement, but would not work because it is financially impossible… But they have succeeded at creating the expectation of universal care, and once you have that… What we’re going to get is Democrats going to a single payer,” he added.
This is indeed what we’ve been hearing and thinking since Obamacare was passed. It was certainly the fear of most people on the right—that the passage and then the implementation of Obamacare would constitute a point of psychological no-return because entitlements cannot be turned back. Even if the GOP could agree on a way to do so (and so far, they cannot), the idea is that the public would not accept that way anymore, because they have become psychologically dependent on it, and wedded to the idea that health care is a right and not a privilege.
But I’m inclined to turn Krauthammer’s idea on its head. I reflect that Obamacare was preceded many decades ago by Medicare, and then in the early part of the 21st century by Part D (passed by the GOP, you may recall). In between (1986) we had EMTALA, the law that guaranteed emergency medical care at hospitals and didn’t really figure out how to pay for it—a law that was passed by a Republican Senate and Democratic House, and signed by Ronald Reagan, as part of a larger bill:
That’s government racketeering explained in a nutshell: create the problem (strain on hospitals due to mandated free care) and use it as an excuse for wealth transfer, which is what universal healthcare amounts to in the end. And look how perfectly it works. The requirements under EMTALA are ostensibly what led to “Romneycare” and inspired the Heritage Foundation and Newt Gingrich to propose government- mandated health insurance coverage, giving liberals and libertarians a fair basis for pointing to “conservatives” as the ones who first proposed health insurance mandates.
Our previous system of health insurance worked pretty well for most people, actually, but it was extremely complicated and quite a few people fell through the cracks. Meanwhile, the growing entitlements (such as EMTALA) were at least part of the reason that health care was becoming more expensive and more often out of the reach of many of those without any insurance. Without going into the ins and outs and the details at the moment, I’ll just say that the expectation that the federal government do more to alleviate the burden was growing and growing and growing, and all the laws that I just mentioned were passed not just to expand those expectations but in response to expectations that had already expanded in a slow but seemingly inexorable progression.
I use that word “progression” purposely. “Progressives” of the left call themselves that in order to promote the idea that their policies represent a natural, normal, and morally good example of human progress going forward in time. But those policies also create dependence, restrictions on liberty, rising costs, and bureaucratic messes that are hard to fix and resistant to change.
Yes, as Krauthammer suggests, Obamacare has “create[d] the expectation that health care is something the government is responsible for.” But it’s also true that Obamacare reflected and was a response to the already-evident fact that the belief that “health care is something the government is responsible for” had been growing and growing for many decades. The details of Obamacare may not (and in fact were not) popular. The idea of it was. The whole thing was a system in which the expectation fed into the legislation, and then the legislation solidified the expectation that something similar would continue.
The current impasse among Congressional Republicans represents a split between those moderates who don’t think we can or should go back very far—those who prefer tweaking Obamacare to keep the general idea in place but somehow make it “better”—and those on the right who think that turning it back entirely (and replacing it with one or another far more conservative solution) is not only possible but necessary for the good of the country and its people. This is a profound split rather than a minor one. It’s also an obvious split, and anyone who worked on a new bill to replace Obamacare had to be cognizant of it.
[NOTE: In yesterday’s thread on the pulling of the bill, several commenters remarked that the 2016 election sent a message to establishment Republicans that they had lost, but they didn’t get the memo. I understand what people who say that are getting at, but I disagree at least somewhat. After all, on the subject of replacing Obamacare, the person whose election most represented that anti-establishment message was Donald Trump, and yet he is also one of the Republicans in government who is furthest to the left on health care reform. No, this does not break down to a simple “establishment versus the right.” Trump’s victory was not a victory for conservatism, you may recall. Although he’s certainly a lot more conservative than Hillary would have been, his conservatism is spotty and inconsistent, and does not include his attitude on health care reform.
Also, see this on the subject of who was to blame for the rush on health care reform. Promises, promises. I blame both Ryan and Trump for the rush (which I see as having been fatal to the effort), and for the failure to design and back a bill more GOP members of Congress would be willing to support.]
Yes, the momentum has been building for decades and expanded Medicaid is the logical conclusion.
I’m sure the stalwart conservative commenters here were aghast when Republicans were responsible for their own expanded entitlement program- Medicare Part D.
When you add Trump’s position on healthcare, it’s not unreasonable to expect that the ACA in some form will continue.
I’m still struggling to wrap my head around the reasons why premiums have risen so much, given that a significant portion of ACA beneficiaries were enrolled in Medicaid.
Is it all due to community rating, guaranteed issue, EHB, the cost shifting of an expanded Medicaid enrollment and the increased expense of reporting regulations? Maybe that’s enough.
Why does the AMA endorse the ACA and not the AHCA? Is it because doctor’s can just shift costs to make up the losses from caring for Medicaid patients?
Here’s the best collection of information about all the disparate elements of the ACA and it’s effects on the health care industry.
http://www.discoverthenetworks.org/viewSubCategory.asp?id=1957
What the last couple of weeks demonstrates is that this won’t be the only difficulty Trump is going to have getting his agenda through Congress. The Republicans are a coalition of two different political philosophies. Throw in the non-ideological position of Trump and bridging the differences is going to be monumental. If Trump does pull it off, he should be eligible for a special Nobel prize.
Remember, the government doesn’t have any warehouse full of free healthcare it can distribute to citizens. If the government gives Paul something, it has to take it from somebody else.
“Everyone wants to live at the expense of the state. They forget that the state lives at the expense of everyone.” Frédéric Bastiat
Neo’s essay is quite wonderful, quite correct.
Democrats know what they want, and strive to get it: government-controlled single payer for everyone.
Republicans cannot, will not get themselves together, addressing the grievous faults of Obamacare (e.g., 85% of previously uninsured are now “insured” in Medicaid, and as many previously insured are now effectively uninsured due to high deductibles and high premiums).
You cannot fix something if you do not know how it is broken. A lot of Ryanesque palaver flatly fails to show understanding of the direction(s) to a solution. Maintenance of community rating and a 30% surcharge payable to an insuror for the great fault of being without coverage for >63 days is preposterous. Thanks, Ryan.
I am being charged a penalty by Medicare every year for not enrolling in Part D at my 1st opportunity. That is offensive, because it does not alter the cost of my “benefits”; I didn’t enroll at first because I did not approve of Part D, and decided later WTF everyone’s doing it.
I despise Medicare, always have, but things keep getting worse. My wife, a rheumatologist, had to do away with keeping simple, cheap splints in stock for her patients, many elderly, because Medicare declared them Durable Medical Equipment, which can now be provided ONLY by DME companies. So two trips instead of one, to screw both docs AND their patients and so achieve trivial cost “control.”
The failed bill failed because at least some GOP reps see a bigger picture than Ryan, who talks big but leads from behind, a small man with small vision. Thanks, Mitt, for elevating him.
Indeed. Note how the expectation, pushed by the “liberal” Hive, is that if the GOP succeeds in doing away with Obamacare, it then has an obligation to replace it with a “better” version. The premise–that providing health care is a “natural” obligation of government–is just assumed and never questioned.
Perhaps the most significant lesson from this fiasco is that Democrats along with the collaboration of Republican RINOs (for whom their personal political survival rates far above what is “necessary for the good of the country”) have now established in America the substitution of essentially a pure democracy for a representative republic.
Republics may survive but democracies are suicidal.
“A democracy is always temporary in nature; it simply cannot exist as a permanent form of government. A democracy will continue to exist up until the time that voters discover that they can vote themselves generous gifts from the public treasury. From that moment on, the majority always votes for the candidates who promise the most benefits from the public treasury, with the result that every democracy will finally collapse due to loose fiscal policy, which is always followed by a dictatorship” – Alexander Tytler 1787
“Democracy never lasts long. It soon wastes, exhausts and murders itself. There was never a democracy that did not commit suicide.” John Adams
“A Democracy will cease to exist when it takes away from those who are willing to work and gives to those who would not.” Thomas Jefferson
It wouldn’t surprise me if in a few years, as the costs continue to rise and the exchanges collapse, Trump makes a deal with the Democrats and a handful of moderates on our side to go full single payer, especially if he decides to be – or events determine him to be – a single term president. As long as the majority of Republicans can oppose it nominally, what have they got to lose?
Employer health insurance. Began during WWII. Became a fixture of the workplace during the 1950s – 60s. Those with jobs and insurance benefits never cared what their health care cost. At the time it seemed quite innocent.
1965 and LBJ got Medicare and Medicaid passed as part of his Great Society program. A majority of people thought it was the right thing to do. At the time it seemed it could be paid for and seemed quite innocent.
1986 and President Reagan signed the Emergency Medical Treatment and Active Labor Act (EMTALA). It was designed to keep people from being turned away from Emergency Rooms because they didn’t have insurance. A noble cause. Few saw the down side and it was well intentioned.
In 1984 (before EMTALA) I had a medical procedure that required surgery and a four day stay in the hospital. The total bill was $2500. My share was 20% ($500), which was my deductible. My employer kept the deductible at 20% of the bill all the way to bankruptcy. (But that’s another story.)
In 1992 I had a small surgical procedure that required an overnight stay in the hospital. The total bill was $14,000. I was astounded. My share was $2800. Being cheap, I complained to the hospital and went into their office to go over the bill – a five foot long computer printout detailing all the charges. A great many of the things I was charged for had not been necessary but might have been and were “approved and customary.” That was when I learned about EMTALA and the costs the hospitals were shifting on to insured patients.
Between cost shifting for pro bono ER work and low reimbursements from Medicaid/Medicare the cost shifting has become the rotten core of our medical care system. Universal healthcare or “Medicare for all” will fix that problem, but like deregulating the airlines, you will quickly have a rush to the bottom and quality of care will suffer. Wealthy people (and our Congress people) will always be able to go to Mexico or some Caribbean island for top notch health care by private clinics, just like some people can fly first class, but the majority of people will get impersonal, assembly line care. That may be our future. It is to weep.
“I use that word “progression” purposely. “Progressives” of the left call themselves that in order to promote the idea that their policies represent a natural, normal, and morally good example of human progress going forward in time. But those policies also create dependence, restrictions on liberty, rising costs, and bureaucratic messes that are hard to fix and resistant to change.” — NEO
Should be on billboards all over the country.
J.J. Says:
March 26th, 2017 at 12:24 am
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Reading your progression (ahem) reminded me of the same process detailed by Jonah Goldberg on a different topic, but with the same effect: gradual replacement of the correct status with one totally opposite (shades of boiling frogs…)
http://www.nationalreview.com/g-file/446081/living-constitution-dianne-feinstein-neil-gorsuch-attack
“But let’s say, for the sake of argument, that after I ordered the Arizona Omelet, the waitress brought me a bowl of oatmeal. I might say, “I didn’t order this.” Waitress: “Yes you did. That’s the Arizona Omelet.” “This is oatmeal,” I’d say. “The menu says that the Arizona Omelet has cheese and onions and jalapenos in it. It also says it’s an omelet.” Waitress: “Well, we here at the Red Flame believe that the menu is a living, breathing document that changes with the times. Oatmeal is healthier than an omelet, and we feel that people should eat more of it. So, we only serve oatmeal, but we call it by different names.” Now, I could have taken up a lot more of your time by making my point more gradually, describing round after round of just slightly wrong orders. That’s more like how the doctrine of the “Living Constitution” works in real life. A judge makes a small leap of interpretation that seems reasonable – say, replacing onions with shallots, which after all, are a kind of onion. Then the next judge makes another incremental hop in interpretation. And then another. And another. Until eventually the waitress brings me the head of Alfredo Garcia (not the one from the movie but Alfredo “Freddie” Garcia, the short-order cook who before his untimely death worked at the Red Flame Diner) who was infamous for his onion breath. But the point is the same. It’s like a game of telephone.”
@JJ – had me most of the way until…
“but like deregulating the airlines, you will quickly have a rush to the bottom and quality of care will suffer.”
If that were true, then it ought to be true of all medical procedures that fall outside “regulated” medical industry.
Don’t see this “rush to the bottom” on quality in laser eye surgery, or plastic surgery, as a couple of cases.
Even the much less regulated veterinarian industry seems to not be such a bottom quality rush either.
That statement is buying into the dem world view and framing.
It is certainly easier to sell a direct “benefit” to someone if there is no perceived “cost” (often, because it is spread out, or is indirect).
Go to other western nations where they have some version of single payer medical care and everyone will describe their system as “free”, or nearly so.
What they don’t tell you is the amount of time they have to wait for service, or that they don’t adopt the latest technology or medicines. There are many “non-monetary” costs that they bear.
Not to mention the talent they have lost, as many top doctors choose to migrate to the US.
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A similar argument can be made on other major government interventions some advocate (e.g. trade restrictions).
One group (wrongly, IMHO) perceives they will be better off, but the cost is spread out and borne by others directly and indirectly.
“One group (wrongly, IMHO) perceives they will be better off, but the cost is spread out and borne by others directly and indirectly.”- Big Maq
But that’s been true throughout our history. I live in an area that exists because the government built Grand Coulee Dam, then diverted water to irrigate nearly 700,000 acres, making it one of the most productive agriculture areas in the country.
Direct benefits were to some people. The indirect benefits to many more.
In your way of thinking, the eight federal dams on the Columbia River would never have been built. They produce enough electricity to power eight cities the size of Seattle. There are, of course non federal dams in the BPA system that produce another 5,000 megawatts of power.
As to access to health care, there are issues that need to be addressed separate from the ACA, like the stranglehold the medical doctor’s guild, the AMA, yields to maintain a shortage of doctors.
That is unfortunate. Medicaid, like other supposedly “socialist” programs, only functions because it is NOT universal, and in fact very specifically limited to people below a certain income. Even “worse,” that income level cutoff changes, not based on the number of poor people that need healthcare, but how many people the Medicaid budget can provide healthcare for. That’s why it works, insteaf of spiraling out of control, requiring an infinite amount of money to sustain itself, and imploding with genocidal consequences, like real socialist systems always do.
We can spend some of the budget on social safety nets, and in order to keep the peace, modern government HAS to. But we can’t sustain something programs that are designed to require an infinite amount of money, and the end result that liberals want (everyone realizes money is stupid and accepts communism as a preferable alternative) is not what liberals will get.
Big Maq: “Don’t see this “rush to the bottom” on quality in laser eye surgery, or plastic surgery, as a couple of cases.”
Those programs are primarily paid for out of people’s pockets. Little insurance or government meddling. Once the government is paying the freight, they will cut the reimbursements because they have the power.
I have related some horror stories about military medicine (similar to what universal care would be like.) here. It is impersonal, assembly line, and mediocre.
I’m on Medicare. I get the statements that show what the providers are asking for and what Medicare is paying. There is a huge gap there. Often as little as 10 cents on the dollar billed. My question is which figure is the real cost of the treatment? Or is it all just a big game?
Universal health care begins with education reform. For example, sexual education is a symptom of an underperforming system… with ulterior motives.
Universal health care? No.
Universal and progressive financialization (i.e. redistributive change a la Fannie/Freddie)? Yes.
Universal health care is a concept embraced by people who recognize intrinsic value, and selectively by people with other characters.
That said, health care reform begins with education reform and moral revival.
“Those programs are primarily paid for out of people’s pockets. Little insurance or government meddling. Once the government is paying the freight, they will cut the reimbursements because they have the power. “ – JJ
True in various ways that once government gets involved things deteriorate.
In large part, it is because they can live on, come what may, while private industry lives or dies by the market.
So, agree in general. Deregulation of the airline industry as a direct comparison is not what I’d pick to illustrate that point.
One could even argue that they are still in recovery mode from the over-regulation they had years ago, which left these companies with burdens they couldn’t live with under competitive pressures.
@Brian – the logical line of your argument ends up with…
“You didn’t build that!”
https://www.youtube.com/watch?v=YKjPI6no5ng
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We can debate the merits of one “public works” after another, and I suspect it would be never ending and without conclusion either of us would find satisfactory.
Many of the same kind of arguments are used to justify a great many “investments”.
Take sports arenas, as just one example. The “benefits”, yes, are arguably “spread out” – all those sports fans can locally watch and cheer their team.
However, what about the non-sports fans?
And, are the benefits really that well spread, or is it effectively a subsidy to team owners?
Oh, it provides jobs and increases the local economy?
But, we never know what that tax money in the people’s own hands would have brought – hard, if not impossible to measure, right? Heck, does anybody bother to ask this before hand?
And now, it seems every city that wants a “Pro team” has to pony up, as they are played off each other for the biggest “subsidy”.
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So, yes, we can talk about dams. Owners of construction companies benefit. Owners of power companies benefit. Farmers, especially the big operators benefit (huge problem in CA, btw, as the farmers are paying a low price for water vs other industries and citizens – think that might have something to do with water shortages?). And, yes, some citizens benefit.
Have you thought of the cost? Or, do you only see the benefit side?
We’ll never know after the fact, will we? Much of it is too spread out and hard to measure.
Was there an alternative? Could the outcome have been more market driven?
Did it end up as originally promised?
Who knows, at this point. All we can see is the “benefit”.
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Like folks in other western nations who like their “free” medical insurance, they fail to connect the slow service, slow adoption of technology, inability of doctors to provide the latest and greatest to the “non-monetary” cost they are, in fact, paying.
Why? They don’t “see” it coming out of their bank account. Yet, they still think it is “free”.
There are costs to most anything government does. And, even when it “does” something, what people envision that it provides is often less than what they thought, if any positive effect at all.
Often, simultaneously, we will find certain groups who seem to benefit. Usually those leaders of the industry being regulated, along with a bureaucracy that would like to expand.
Few bother to think of these things when asking our government to do that “something”. Nor, bother to measure that against the probably over exaggerated benefits.
Few bother to think that maybe the more power we put into governments hands, the more unwieldy and opaque it all becomes, and the more subject to abuse it becomes.
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So yes we can justify in many ways government’s involvement for all kinds of things. But I don’t think many go into it with eyes wide open and understand the full consequences. They see their benefit and it ends at that (even assuming they assessed that correctly – often it is wrong).
In the end, we all end up “paying”, one way or another, blaming the left or the right, when it is ourselves who are demanding this, and failed to realize the aggregate consequences of our demands.
I am 73 years old and I’ve had my own insurance all my working life. When I retired I intended to continue my own insurance without recourse to Medicare. The company I was with informed me that if I didn’t take the government insurance (which would be, then, primary), they would raise my rates by nearly double.
If I remember, when I first heard about “the great health care controversy” – I believe it was Hillarycare at the time- people I know were kind of buying in because our assumption was that a major health problem like cancer, could easily bankrupt you and even very good insurance plans would drop you at some point, perhaps even during a critical time in the treatment. Some kind of solution to that problem seemed to be something the Government could usefully be involved in. Those of us approaching retirement lived in fear of that akin to fearing the bomb as children. The possibility was always in the back of your mind.
I don’t, or didn’t then, know anyone who wanted the govt. involved in our day to day health care.
It appears that our betters are determined to “Help” us come hell or high water. The arrogance/condescension of that attitude is palpable.
Big Maq: “One could even argue that they are still in recovery mode from the over-regulation they had years ago, which left these companies with burdens they couldn’t live with under competitive pressures.”
Since I earned my living in the airline business and was present before and after regulation, I know what happened. However, you’re correct that the analogy isn’t quite correct.
The airlines are in an industry where they have two basic things to sell – a route (where you want to go) and a schedule (when you want to go). The airplanes may vary a bit and the seats may vary a bit, but the product is basically the same (except for first class) from one airline to another.
The route and schedule planning is done by computers to maximize availability during periods of demand and minimize expenses during times of low demand. Other than that the only thing they can do to attract passengers is to cut fares. The passengers (except corporate and government) are making choices and paying out of pocket for what they get.
Deregulation resulted in a large number of start up airlines that had very low expenses. They leased their airplanes, they contracted for maintenance, baggage handling, and training. They did not have very high expenses for infrastructure or employee benefits.
On the other hand the established airlines had large maintenance facilities, large loans on aircraft they had purchased, big training centers, employed mechanics/baggage handlers/aircraft cleaners with full benefits, and had big costs for employee benefits, retirements, health insurance, etc..
The established airline managements were very slow to recognize what was happening. Though they quickly recognized the need to lower employee costs. All of the majors have been at war with their employees since deregulation. This has resulted in bad feelings among employees, low morale, mediocre service along with bankruptcies and mergers needed to survive.
The majors found that even though they had good routes and the right schedules, they were losing passengers to the low cost carriers. At first they believed that eventually people would want better service with complimentary meals, etc. They were wrong. Everyone went for lower prices to hold passenger load factors. To pay for the extra overhead the established carriers did away with perks, and instituted charges for things like baggage, reservation changes, etc.
Today we have an airline industry with mediocre service that competes only on price. Yes, it is driven by free market forces, but it still remains highly regulated. The government still controls the air traffic system; licensing requirements for aircraft, pilots, and mechanics; control of the training standards; and more. The government operated air traffic system is outmoded and inefficient. It adds millions of dollars of extra fuel costs each year as well as delays and cancellations that need not have happened.
One of the airlines’ major customers is the U.S. government. They have the bargaining power to get the lowest possible fares. If the government was the only customer, as it would be in universal healthcare, can you imagine how low they could drive fares? That’s what would happen in universal healthcare. The providers would not be working for the patients, but for the government.
The US Republic died a long time ago. Even the Southerners were fooled into thinking US Civil War 1 was about states’ rights. It was about the Federal Slave Fugitive Act and empowering it, not about the states like New York, using nullification to ignore federal laws. Southern states used nullification against Brown v Board and other federal writs.
“Yes, it is driven by free market forces, but it still remains highly regulated.“ – JJ
Thanks for the detailed explanation. Much very agreeable there.
Where we disagreed was on the emphasis of deregulation as the cause.
One of the things today’s regulations seem to do is limit the possibility of more competition, not just in airline operators, but even to the point of growing airport capacity.
So airline flights have become more of a commodity product, not much different than long distance bus service.
Airline industry is ripe for disruption, with how our technology is evolving, not unlike the taxi industry is and will. It won’t for some time due to the barrier that regulations create, but it may in our distant life times.