Just a pair of tweets as to why I am so passionate about continual healthcare reform and system improvement:
The good news:
As open enrollment begins today
The Impact of Obamacare, in Four Maps https://t.co/KKiDuBExx0 pic.twitter.com/0PhVc8XuMR
— Andy Slavitt (@ASlavitt) November 1, 2016
The bad news:
The gap in life expectancy between Connecticut and Louisiana is the same as that between the US and Nicaragua. https://t.co/L2eACtQiMM
— NY Review of Books (@nybooks) October 31, 2016
We can do better. This is a failure of our political and cultural system and we need to do better.
Barbara
The good news is especially good where states have expanded Medicaid. You can pick two states with some similarities and see the difference — Maine and Pennsylvania in 2015 versus 2016. Or Arkansas and Mississippi.
Chris
@Barbara:
That’s one of the main reasons I moved from Florida back to Maryland the instant I was done with grad school.
the Conster, la Citoyenne
Almost half the country is voting for a person who represents every failure of our political and cultural systems, so yeah. Long row to hoe.
Dr. Ronnie James, D.O.
I just interviewed for an FM residency at a FQHC that serves Eastern Queens/ Western Nassau Co. – a high-poverty, deeply underserved area, one of the worst in NYC. Towards the end, the director (Caucasian doc, early 60s) just started ranting about how Obamacare was “a disaster” and “we need more competition in health care.” Keep in mind: his hospital is publicly managed (NYS), his clients are largely on Medicaid, and residency slots are predominantly funded by Medicare. sigh.
Cermet
The tragic nature of those living in our third world places continue to be that they vote thug in a desperate attempt to create a lower class of people in the hope that this will enable them to feel better; they gave up hope of making a better life for themselves and children generations ago … that has to change and we liberals need to take that seriously.
Barbara
@Dr. Ronnie James, D.O.: The acculturation of doctors over the age of 60 was steeped in the mythology of personal merit and individual success, probably until the early 90s. I remember reading an article from a doctor who said that when he used to attend local medical society events it was like a meeting of the Chamber of Commerce, and that now, it’s more like the organizing meeting of a labor union. Through the 19th century, doctors were among the most politically radical professionals. In the U.S., at least since the 1940s, doctors were co-opted by what one of my professors called the golden age of reimbursement and that has worn off only very, very gradually.
Betty Cracker
@Dr. Ronnie James, D.O.: My sister and SIL are medical professionals and Democrats who support healthcare reform. Doctors are really divided about it, from what they tell me, with some recognizing that the pre-Obamacare system was untenable and others fancying themselves oppressed by the state in the post-Obamacare world, etc.
I do think the nature of Obamacare — its attempt to jury-rig the existing employer-based and Medicaid systems, the SCOTUS-granted outs for state leaders who would rather see their poor die than legitimize government-sponsored reform, etc. — add to the problem of negative public perception. People just don’t have a fucking clue how it works. They can’t easily discern the bad faith with which state actors like Gov. Scott operate.
But Obamacare was what was possible in 2009. Anyone who thinks Medicare for all had a chance with the Congress at that time was clueless then and doubly so now. Even if Hillary Clinton wins in a landslide, I don’t see much of an opportunity to revisit healthcare reform aside from some tinkering on the margins for a very long time. I hope I’m wrong.
Schlemazel
@Cermet:
And how would you suggest we do that, exactly? Present them with the numbers showing what they are doing? Offering programs specifically designed to help them? Holding serious policy discussions that highlight the cause & effect? What do we need to do to “take that seriously”?
Barbara
@Cermet: Cermet, that really is not correct. First, in many of these places, those who are not white are not voting Republican. And this is also the case — even in many southern states — for whites with the lowest incomes. The life expectancy of people in Louisiana likely varies dramatically by race and by income level. It probably also varies by proximity to the area where oil refineries and chemical plants are concentrated (which is sometimes called Cancer Alley). The same is probably true but to a lesser extent in Connecticut.
CaseyL
Louisiana is in its own category for corruption and mismanagement. Bobby Jindal ran the place as though he had a personal vendetta against it. He systematically destroyed the state. Bel Edwards is doing his best to fix, but fixing a complete collapse is much more difficult, takes much longer, and costs much more than fixing more ordinary failures.
I’d be more interested in how the gap analysis plays out in places like Mississippi and Alabama, where there’s still enormous amounts of institutionalized racism and economic inequality, but where the governors try the whole actual “governing” thing far better than Jindal did.
WereBear
@Chris: I left Florida for New York at age 20. I did not realize it would be one of the most profound decisions of my life.
I left for Culture: I had artistic ambitions. I left for culture: as a woman in the south, I would never be taken seriously.
But I never thought such a decision could possibly save my life. The support of government in NY is much much more serious than Florida; who makes it so difficult to have an abortion, takes the babies away once they have emotional problems, breaks foster parent’s hearts by not paying for the physical or mental care they need; and then has a batch of new dysfunctional citizens they won’t take care of.
It really is that stark.
Elizabelle
Great post. Thank you for this. Look forward (I guess) to reading Nathaniel Rich’s article later.
Healthcare is so important, and we CAN do this. It’s why all that Koch/other oligarchs’ money and big broadcaster spin and deflection is out this election season.
The Moar You Know
Obamacare is a disaster, because it puts the onus of delivering quality healthcare on institutions (insurers) who have no reason to do anything to make healthcare better – their sole concern is profit.
Not to say the GOP route is any good; they simply want to repeal and replace with nothing, or as our ol’ buddy Alan Grayson said “die quickly”. Ever wonder why the GOP got so up in arms over that statement? Because it’s true. That’s what the GOP wants.
Repeal and replace with single payer (yeah, I know it’s not happening in my lifetime, but that really should be the goal).
gene108
If Medicaid expansion were adopted by all states, we would be close to universal coverage.
Roberts and the Republicans really fucked over millions of people.
@Cermet:
Lower classes do not often vote.
LAC
@The Moar You Know: so you are for the handwringing and purity pony bleating about single payer rather than fixing the affordable care act ? Great….
Chris
@WereBear:
I’ve got a story that goes right along with that.
My last couple semesters in Florida were spent working at a tourist gift shop in a small town while living with my grandmother (I needed the money if I was going to avoid taking out another $10,000 in student loans). Halfway through that, I got a new co-worker who’d just moved back home from New York City. Since we both were about the same age, made the same amount of $$$, and had medical problems (though much more serious in his case; I had IBS, he had seizures), we ended up talking a lot about safety nets and the like. The programs he described in NYC really made me drool (especially post-ACA) in terms of how much better they were (Florida has no Medicaid for the poor, except those who have dependent children; not even if you’re jobless and earn $0.00). But of course, taxes were higher in New York. And he was actually happy that he was back in Florida, because, the way he put it, while he earned less money here, the lower taxes meant that he actually had more left in his pocket at the end of the day. A point I could never agree with – “yeah, but you have no health insurance! [and you really fucking need it, you, in particular].”
So anyway, the end of the year rolls around; I quit the job, say goodbye to everyone, move back north to live with friends and look for work in the DC area. (And get on Medicaid, praise the Lord, Medicaid at last).
A few months later, I get a notification in my Facebook mini-feed that said my co-worker passed away.
I don’t know what he died of; we didn’t have any friends in common I could ask, and the shop we used to work at closed down in the meantime so I couldn’t even have called that number anymore if I’d wanted to. I can make a pretty good guess, though, that the medical problems he was already suffering from caught up to him. And that if he’d still been living in a place like NYC, with all the lavish insurance and other public assistance programs he was describing, they might not have.
The absent safety net really and literally kills people, all the time. And so does the penny-wise-and-pound-foolish mentality of “all right, I have a lot less, but my taxes are down!” Suffice it to say I completely believe you when you say that moving from Florida to New York saved your life.
Chris
@gene108:
There is no hole in hell deep enough for that.
And if there’s a hell, or at least a purgatory, I hope Roberts is forced to live through all the medical problems of each and every citizen that he fucked over with his Supreme Court decision, in turn. And then, to live through all the non-medical problems suffered by the many people who did get their medical problems addressed, but had to go broke in order to do it.
Villago Delenda Est
@Cermet: One of the huge problems we have is that many of these people cannot be reasoned with.
I don’t know how you fix something that badly broken.
p.a.
Federalism; The Mississippi/West Virginia (sorry John) Plan. Proven wrong since the Redeemer regimes. And still held up as a viable system of government. Makes me want to puke.
The Moar You Know
@LAC: It’s not fixable. And that’s become pretty obvious to most people. To those who it’s not obvious, well, it will become so.
It’ll get “fixed” dozens of times over the next few decades. Of this I have no doubt. But everyone knows what the right thing to do is. Do we have the national will to do it? No. Will we? I don’t know. But I do know this; odds are pretty good I’ll live another forty years. And I’m pretty sure I’ll go to my grave and America will still have people without insurance, and (the real problem) people covered by insurance that isn’t worth a damn.
gene108
@Betty Cracker:
A large chunk of the middle-class, i.e. the people who regularly votes, have always had employer based insurance, which was very good.
The inequities of the pre-ACA system never touched them.
This was especially true in the 1970’s to the 1990’s, when employer sponsored insurance pretty much reimbursed everything and the employee cost share was zero or negligible. Then, for whatever reason, in the early 2000’s, health insurance costs really started to skyrocket. They had gone up before, but it had not impacted people as much, with regards to downgrading benefits.
But for a lot of people, especially in bigger companies, benefits could still be pretty good.
So it’s hard for a lot of people to see, why changes had to be made, because there situation would not be impacted and so they blame any negative impacts on the changes to the law, rather than an employer trying to save a few bucks or insurance company trying to save a few bucks.
It’s really hard to get people to understand things that do not directly impact them, which has always been the sticking point for healthcare reform, because most people had insurance.
The reform was to help people on the margins.
gene108
@The Moar You Know:
I disagree.
Between disinformation from the right-wingers, which isn’t helped by left-wing screeches for single-payer or bust, and good old fashioned mean spiritedness towards our fellow citizens, I think a lot of people are confused about what to do.
ET
Red state America still seems to be failing its citizens. But less guv’ment!!! with the added bonus of not having to live as long under its yoke…..
Betty Cracker
@gene108: I think that’s absolutely right. And now that many folks with employer-based insurance see their out-of-pocket share and premiums going up, they blame Obamacare even though employers have been shifting a greater share of costs to employees for decades and double-digit premium hikes were a thing back when Obama was in law school.
@The Moar You Know: I think you’re right too, except that, as Gene pointed out, a lot of people really don’t get it. But Obama himself said single-payer is the right thing to do before he was president — if we were starting with a blank slate, it makes the most sense. But we started with our crappy profit-driven system, clueless consumers and spineless legislators, so here we are. I think you’re right that the “fixes” will continue long after we’re gone, absent some catastrophic shock to the present system, which I don’t rule out.
Villago Delenda Est
Once again I must point out that what people actually want and need is health care, not health insurance. The ACA at least started us down a road to actually deliver care to people who need it. This is how they function in civilized places, like Europe and Canada.
WereBear
@gene108: I point out to people that it is also a way of keeping health care costs down, but it’s an uphill trek, because:
Understanding economics is 99th percentile.
I’m not talking PhD level theories: I’m talking about understanding how money works. I can’t balance my checkbook without a calculator, but I have gotten a pretty good grasp of the subject from reading, and the more I talk to people about it, the more I understand they know absolutely nothing about it.
That’s a problem.
burnspbesq
@The Moar You Know:
Sorry, but that’s obviously not true, unless you’re using a funny definition of “everyone.”
Also, if you want to argue that systems based on private insurance are inherently unworkable, how do you explain Switzerland?
msdc
@The Moar You Know: In the future, please quote Alan Grayson in the first line of all comments so I can stop paying attention that much sooner.
RaflW
@gene108: A big part of the problem is that for so many people with employer-based insurance, they blame ACA for the price hikes being passed thru their paychecks. Part of that might be legit, since ACA doesn’t allow some of the holes in insurance that kept it cheaper for group plans (I think that’s right, this isn’t my area of deep knowledge).
ACA has given employer’s a fantastic boogyman to blame for broader healthcare cost increases — man of which have to do with our aging, lazy, obese population, not ACA.
@Betty Cracker: “They can’t easily discern the bad faith with which state actors like Gov. Scott operate.”
Look at WI on the map in the OP. I don’t know what happened in 2015, but in ’13 and ’16 they are sucking vs. neighbor (and my home) MN. That’s on the WI g.o.p. and Scotty squint-eye Walker. Plain and simple side-by-side. But to Wisconsinites even know?
What they see if they live in the Twin Cities TV market is our (admittedly bad) price hikes and coverage changes for 2017 in MN. And we are in a state that doesn’t allow for-profit health insurance.
I hold some modicum of hope that as this massive kludge system continues to struggle, that we can at the very least create some opt-in single payer system for those states that want it. If the House stays anti-Hillary, it will be very difficult.
Our f’kd up media obsesses with emails while unprecedented obstruction goes on in Congress such that we can’t take a single legislative wrench or screwdriver to the grinding gears of AKA (Affordable Kludge Act). Bah!!
Barbara
@burnspbesq: Jacob Hacker had a very good Op-Ed in (I think) the NYT about what to do. In order to make ACA workable you have to make it work on two different fronts — payer and provider. Right now, ACA works only on the payer front and does not require providers to offer reasonable rates (the way Medicare does). Setting up a so-called public option would work on both of the fronts by telling health care providers that the default in the absence of private insurers is Medicare rates, or something close. I am not going to argue the ins and outs of the benefits and excesses of the Medicare program, but it is clear that one reason why it works alongside private plans is that it controls provider rates.
Enhanced Voting Techinques
@the Conster, la Citoyenne: Yes. how does one help a group who views the act of helping as evil?
gvg
@The Moar You Know: If we got single payer, we would also have to spend decades “fixing” it too. It would have flaws and shortcomings, some would not have been obvious before enacted and others would have been seen but not been certain. Estimates of costs and revenues would turn out to have been imperfect. And time and changes would keep occurring which would need other adjustments just like social security and all other long term programs worth keeping.
Some of the problems I see, would not be significantly different with single payer such as now more mental health is covered but we don’t actually have enough trained providers to fill the need and it will take some years to get there with training.
ACA has just as much potential but it does require people not getting too discouraged. This kind of job is never done. it goes on forever. that is not reason to feel bad, its just normal human life.
Matt McIrvin
@The Moar You Know:
This is an absurd statement.
It can’t be made perfect because nothing is perfect, not even single-payer healthcare. It could be made vastly better in blatantly obvious ways. Even if conservative states will not expand Medicaid, the subsidy donut hole opened up by their refusal to do so (which the ACA never took into account, because of a failure to predict the mind of John Roberts) could be fixed. The subsidies could be increased and the cutoff made gradual, to help the people who are currently being screwed by rising premiums.
Those are fixes, to my mind. Gigantic fixes.
The reasons none of this is happening are purely political. The reasons we can’t have single payer are also political, though, so if you credit one as impossible the other is even more impossible.
RaflW
@burnspbesq:
I am not an expert, but I was born there, and my family retained lifelong friendships with Swiss residents. So I’ll take a stab at it: Culture.
Swiss culture is strikingly different from American culture.
Take, for example, the 50 to 100 year mortgage. Yep, the Swiss have them (and you can pledge part of your pension to count for 10% of the house ‘equity’). And they don’t abuse them the way Americans would. I mean, can you imagine? We’d have a bubble economy so frothy Alan Greenspan would suffocate.
To grossly generalize, the Swiss are quite rule-bound and like it that way. Their precise and orderly way of life (and a bit of a desire to impose that order on neighbors and friends alike) fits a public mandate/private provider system well.
Their considerable homogeneity helps, too.
Our wild-west, responsibility-shirking culture can’t really handle the same package. And by that I want to impugn for-profit insurance and hospitals as much as the populace.
RaflW
@Barbara: I do wonder if we can get to a point that Medicare could be made a national opt-in for 55+ Americans as a next step? Those between 55 and traditional enrollment age would have to pay full freight on the premiums, but would get access to the same bulk-negotiated service prices.
And then as those 55+s start liking the system, the opt-in age could be dropped?
Sort of a sneak-attack way of getting to single payer?
WereBear
What will work to bring the Tea Party back to sanity? I’m thinking: NOTHING WILL.
Inside the Sacrifice Zone:
Villago Delenda Est
@WereBear: Some people have real problems with understanding the relationship between cause and effect.
Brachiator
@Elizabelle:
I definitely have to look at the Rich article in more detail later. But, damn, it is dripping in (maybe unintentional) condescension:
One other thing that struck me is that there are people so affluent and who live in such comfortable circumstances, that they can deliberately jeopardize their health for years and still have good life expectancies. This is the group that includes anti-vaxxers, who indulge in pointless exotic diets, who can subject their bodies to unnecessary cosmetic procedures, etc.
So you have a class of people who don’t even have access to basic medical care, and a class of affluent people who live in a post-medical world.
Betty Cracker
@gvg: You’re right that it’s a job that’s never completed. But here’s where you lost me: “ACA has just as much potential.” I don’t think so, unless you redefine ACA to include the current system morphing into a nonprofit system. The ACA has done much good, but we’re still paying insurance company CEOs tens of millions of dollars a year, maintaining scads of disparate claim processing systems, etc. There’s just a shitload of waste and greed channels in a multi-payer system; it’s the nature of the beast.
@WereBear: Le sigh. Some people are just morons. We’ll have to work around them, like RaflW’s sneak-expansion of Medicare suggestion above.
Brachiator
@RaflW:
Didn’t an anti-immigration party win significant gains in the last round of elections in Switzerland? There’s a downside to homogeneity, I guess.
Sergio Lopez-Luna
@RaflW: I believe Switzerland abolished for-profit health insurance. All insurers have to be non-profit.
narya
Richard: What’s happening in Wisconsin??
Brachiator
@Sergio Lopez-Luna:
I ran across this 2011 article about Swiss health care. Have things changed dramatically since then?
Barbara
@RaflW: This is a serious question. The short answer is that it can’t work the way it works now because those 55 year olds are along with the rest of us financing the over 65 year olds. For Social Security, on average, beneficiaries take out what they put in. For Medicare, current beneficiaries receive benefits that cost more than three times what they have paid into the system. So there will have to be significantly more financing. I suppose you could have an employer provided option that establishes a per employee cost to participate in Medicare, or one of the Medicare options. But the biggest obstacle to doing this is that providers do not think Medicare pays enough and the more people who are “converted” from commercial rates to Medicare rates the more likely it is that they will destabilize commercial insurance with rate increases. Commercial insurers are more efficient than Medicare in a lot of ways (e.g., information management, real time data on care — whereas the government can take months), but Medicare has the iron fist of the government when it comes to imposing rates. The threat of a public option might make these two play together to give us the best of what they have to offer. This is more or less what Jacob Hacker was arguing.
Splitting Image
@narya:
Scott Walker.
narya
@Splitting Image: Well, yes, the goggle-eyed homunculus (copyright Pierce) is awful, but why are uninsurance rates going up? In what looks like all other states, either the uninsured rate stayed high, or it got a bit lower, but in WI it looks like it went down and then up between 2015 and 2016, and Walker was gov the whole time.