Honest Questions about Obamacare



Patrick is a mid-40 year old geek with an undergraduate degree in mathematics and a master's degree in Information Systems. Nothing he says here has anything to do with the official position of his employer or any other institution.

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187 Responses

  1. “If we had some system of exceptions with coverage for free riding or late opt-in, something like one or all of the above in combination, would that answer the objection to the mandate?”

    I’d say with a sufficient system of exceptions, we wouldn’t need a mandate. To your last paragraph, however, I would say either that parents must opt in for their children, or some sort of guaranteed payment for them, perhaps recoverable from the parents, might be necessary.

    My personal support for the mandate is grudging, based on what’s doable with the political will we have. I would have preferred some system of penalties for opting in too late. (I’ll say in passing that until the exchanges opened and I started learning more about it, I didn’t even realize there was an “open enrollment” period. I thought people could enroll any time. So that’s a non-fine “penalty,” or at least incentive to enroll early, with or without a mandate.)Report

  2. Avatar zic says:

    At that point, a single-payer system would be preferable, wouldn’t it?Report

    • Avatar Burt Likko says:

      A single-payer system would be preferable in any event.Report

    • Avatar LeeEsq says:

      Yes but our political system gives the ideological and other opponents of single-payer too many veto points. You need to basically have a liberal sweep of the Presidency, Senate, and House in order to get single-payer passed.Report

    • Avatar BlaiseP says:

      Single Payer avoids a tidy definition: the devil, as usual, is in the details. I favour Single Gateway, taking the model for clearing bank checks. The insurers, like the banks, would have to keep a certain amount of money available for paying claims. The physicians and hospitals would submit their claims through the common gateway.

      I’ve actually written something very much akin to this for the Blue Cross / Blue Shield franchises. A patient from Illinois presents at a hospital in Louisiana with an Illinois card. The hospital is set up to submit all BCBS claims through the Louisiana gateway. The BCBS system looks at the card ID. Knowing it’s not a BCBS Louisiana card, it pushes it into a hub-and-spoke messaging system, sending it to the central Association, which then routes it to the correct BCBS franchise.

      Several serious problems arise, all congruent with the problems associated with accepting a check for payment. TeleCheck * and other such services can pre-approve a check for the merchant.

      But more substantive problems arise around identity and security. Medicare suffers from many fraudulent billing schemes. Hard to catch these people. Private insurers face the same problem. Arsonists intent on collecting on homeowner policies, life insurance scams — for every such legitimate dollar of insured benefit, two dozen scams try to steal it. Again, the check approval model would serve as a backstop for some of this — but not all.

      More significantly, we’d need some scheme of federated identity management and it’s here where people will balk. Congress has refused to address the issue effectively. Thus arise the Ed Snowdens to point out how the government has blown down the doors to privacy with the best of intentions. Where the government should have acted to keep us secure in our persons, it has been stupidly futzing around with the Social Security Number, the state driver’s license, the telephone number, all sorts of lunatic schemes everyone knows won’t work. We don’t trust the government because it’s too stupid to know how to manage a trust relationship with us.

      * Not to be construed as advertisement or endorsement of this service. I’ve written interfaces to TeleCheck for clients who do routinely use these services. It is my opinion such services can serve as a model for a more efficient variant of Single Payer based on the model.Report

      • Avatar Michael Cain says:

        Medicare suffers from many fraudulent billing schemes. Hard to catch these people.

        What are your thoughts on data mining to uncover candidates for a real audit? Seems like the cases I read about all should have been detectable by relatively simple software looking for the right sorts of anomalies in the data. But perhaps that’s just because they’re catching the stupid crooks?Report

      • Avatar BlaiseP says:

        Fraud detection is not all that difficult, technically. You’d work back from the forensic evidence provided by already-detected frauds, constructing patterns for it. Bayesian fraud detection is very well understood by the credit card firms and all of it could be applied to health care fraud.Report

      • Avatar zic says:


        I believe that there have been efforts for fraud detection in Medicare/Medicaid payments for at least four decades, if not longer.Report

      • Avatar zic says:

        An added thought:

        Fraud here needs careful defining.

        Billing fraud would be billing for services not provided or mis-billing services provided as other, higher-paying services.

        There is another level of fraud, and that’s providing services not needed because the provider is paid per service.Report

      • Avatar BlaiseP says:

        Whatever Medicare is doing, it’s simply not working. As more people enter the Medicare / VA / Tricare / Medicaid system, the problem has gotten deeper and wider. Florida’s a magnet for such fraudsters. Pickpockets need a crowd and Medicare fraudsters need both a crowd of oldsters and lax enforcement.Report

      • Avatar BlaiseP says:

        I might add the state programs are even more vulnerable to fraud.Report

      • Avatar Patrick says:

        I might add the state programs are even more vulnerable to fraud.

        This is true, but a different type.

        Look, I have to be honest, I’m getting tired of pushing rocks up hills, with capering howling monkeys jumping up and down on the top of them and flinging poo at me, telling me that they know better, they understand better, they believe and have faith and that protects them from the dangers of the night. And those scary, scary dangers include this rock, that I’m just trying to get up the goddamn hill.

        Most of these people don’t live where I live, disdain how I live, and want desperately to go and jump in a wood chipper. They’re convinced it’s a grand old idea. They’re incensed with me that I forbid them to jump in the wood chipper. They’re so incensed about it, they’re setting fire to the whole village at the base of the hill, which I’m trying to protect from this rock, which is why I’m pushing the fishing rock up the hill in the first place.

        Now, I know for a fact that maybe after five or six of them jump in the wood chipper, the other twenty million of them will get the idea into their fool heads that jumping into a wood chipper is a stupid, stupid idea. The first five or six of them, well, they’re fools and probably fools don’t deserve to die just because they’re fools.

        But I’m just done caring about them, because I gotta get this rock up to the top of the hill and then run down to the village to help put out the fire, which is threatening a lot of people who just want to get on with their lives.Report

      • Avatar BlaiseP says:

        Gegen Dummheit… Against stupidity, the gods themselves struggle in vain. Well, Patrick, I don’t struggle any more. I’ve yet to see the facts change anyone’s mind against their will. People were willingly burned to death because they didn’t believe wine was actually turned to blood and bread to flesh. It’s pointless debating them. Facts only annoy them.

        I used to be disgusted. But now I’m just amused. I write my little comments, I don’t take any shit from these people. A few thoughtful folks are worth the trouble — but their minds aren’t made up. They, like me, look at what few facts are on offer.

        People like me know the insurance firms are hiding their actual statistics, know the health care providers exist in a wildly distorted market where they can’t figure out whether to shit or go blind about getting paid for what they do. The Baby Boomers are doing what they’ve always done, hog up the majority of the resources and screw everyone else.

        Camus said Sisyphus was happy.Report

      • Avatar Patrick says:

        Camus said Sisyphus was happy.

        Maybe that’s the fundamental difference between me and the libruls, Blaise, maybe they’re just happier about pushing rocks up hills. I’ve got too much Irish in me to put up with this stuff with a grin on my face, and a bit too much German not to be something of a vindictive bastard.Report

      • Avatar BlaiseP says:

        Nobody makes me push the rock. My entire world fits into the back of an Isuzu Rodeo. I’m a liberal because I don’t feel I have much of a choice. Nobody ever did a whole lot for me. I did a whole lot for other people, for various reasons. I’ll never get out of life what I put into it. I’m a man of numbers and algorithms. But I’ll be damned if I’ll run around and whine like these innumerate conservatives who can’t figure out we’re all in this together, that there’s more to be gained by harnessing the power of numbers than any other possible strategy.

        I’ve done it on my own. Very few people get to say that. Very few people fly that close to the sun. It’s forever a source of darkest amusement, to watch people who’ve never actually been truly responsible for their own choices, who’ve never been laid up in a hotel room, a long way from anyone who cares, scared of dying alone — preach about the virtues of that life. I really would like to grab a few such people and make them spend eight years in hotel rooms and endure the vagaries of that fate.Report

    • Avatar Kazzy says:

      Can someone give me a nutshell explanation of what single-payer is? I feel like that would be helpful, as I see the term used a lot but realized I don’t know quite what it means.

      Is Britain single payer? Is Canada? Are they different? Recent conversations imply that they are, but I’m not sure how.Report

      • Avatar BlaiseP says:

        Single payer, simply put, is the government writing the check paying the health care provider. But that’s essentially what happens when a check clears: the Federal Reserve system shuttles money around between the banks.Report

      • Avatar BlaiseP says:

        Single Payer is not government health care. That implies the government is the health care provider.Report

      • Avatar Kim says:

        Government as sole insurer.
        (as opposed to “single provider” where we nationalize all health care.)Report

      • Avatar zic says:

        Here’s a primer fron Frontline.

        Nutshell: there are 4 basic versions.

        1) Belvridge System: paid by government, financed by taxes. This is the UK system.

        2) Bismarck System: Similar to the US system, funded through employers/employee contributions, but not-for-profit and everyone’s covered; used in Germany;

        3) National Health Insurance: Paid via government, funded through taxes, but uses private providers;

        4) Out-of-Pocket model: pay out of pocket, no can pay, no treatment; used in 3rd world and many developing nations; this is the model used in India.

        The US has several overlapping models; VA care through the VA is #1, Medicare/medicaid is #3, for the uninsured, we get #4, and most employed/insured people get #2, but there’s profit motive involved.Report

      • Avatar Kazzy says:

        Thanks, @blaisep .

        Is there typically a list of participating and non-participating providers?

        Would a rough analogy be the proposed voucher system for education, wherein the government agrees to foot the bill (up to a certain amount) and the user can utilize the provider of their choice?Report

      • Avatar BlaiseP says:

        The precise analogy is the routing transit number. The health care provider presents a claim for payment against a insurer. The mechanism which pays him would interface with those RTNs. Every patient would need one, too: the provider has to make a claim against a specific person.Report

  3. Avatar roger says:

    My recommended plan includes the freedom of a notarized opt out. I agree the premium would need to increase for each year uninsured if they later decide to join.

    In other words, I love it. I think the net result would be just about everyone joining the plan without making it coercively mandatory.Report

    • Avatar BlaiseP says:

      And we roll Tommy Boy, notarised document and all — out onto the sidewalk and leave him there.Report

    • Avatar Kim says:

      So long as the “freedom of a notarized optout” isn’t ANOTHER handout to Walmart!
      [yes, I realize that you weren’t actually suggesting that.]Report

    • Avatar zic says:

      There are a few big problems with this.

      But the one that most disturbs me is the role of first responders and bystanders. Say you’ve opted out, and you’re in an accident; unconscious, and need to be cut out of your car by first responders. They don’t know you’ve opted out, they don’t know (or care) who you are at this point. You are asking these people to do heroic work to get you out of that car to then, what? Just let you bleed to death?

      Or you’re in a restaurant, and you have a heart attack. What do all those innocent people around you do? Call 911 or ask you for your insurance? If you say, “No, none,” do they just put you out on the sidewalk and go on with their dinners?

      I worry about the fraying of cultural norms under such conditions; and I’m not one prone to worrying too much about cultural norms; I find most folk cling to them too closely. But this is one messed up scenario where I see some serious damage happening to the fabric of our lives.Report

      • Avatar Kazzy says:

        @zic ,

        What I find interesting about what you bring up here, especially with regards to social norms, is how many people would say, “Of course first responders should do everything in their power! Of course fellow diners should act and call 911!” (which I presume would be everyone) and then how many of those people would say, “Cut off his care!” (not everyone, but a not insignificant portion of the populace).

        I recognize those situations are completely irreconcilable, but I’m curious how many people have actually gone through the work of reconciling them… morally, ethically, logistically, etc.Report

      • Avatar Kim says:

        Yes, in America, this is often what happens to people without insurance.
        Not necessarily with heart attacks, but I’ve known people who have died because
        their insurance was that bad. Others who fled the country.Report

      • Avatar Mad Rocket Scientist says:

        I think Patrick addressed emergency care by saying:

        … the Feds pay the hospital so no other citizens are left directly holding the bag, and then the Feds (through the IRS, probably) garnish Tommy’s wages over X years, charging him interest at the Fed Window rate until he pays it off.Report

    • Avatar Kazzy says:


      Sounds like another handout to Big Notary.Report

    • Avatar roger says:

      “…the Feds pay the hospital so no other citizens are left directly holding the bag, and then the Feds (through the IRS, probably) garnish Tommy’s wages over X years, charging him interest at the Fed Window rate until he pays it off. Again, there are some heavy details to iron out, but is this a deal breaker for anybody?”Report

      • Avatar zic says:

        Roger, consider, just for a moment, the possibility that the only value you’re considering is economic value; the only freedom economic freedom.

        There are so many other values and freedoms to weigh. Please don’t forget them. My peace of mind that I can help you when you’re in need without wondering if you’ve got your insurance papers is one of them.Report

      • Avatar Kim says:

        even if we only look at economic freedom, there is still a solid argument that the mandate does a good job of increasing net freedom, due to reducing aggregate costs.
        The money saved /is/ one measure of economic freedom.Report

      • Avatar roger says:

        Please do elaborate, Zic.

        I am providing a recommendation for universal catastrophe care for all Americans, and subsidies for all poor people. I am recommending a system which re-introduces a mechanism for creative discovery into the health care industry for the well being of billions of people in the future.

        How can this be read as a only valuing freedom and economic value?

        Just to clarify, Patrick clearly recommended that nobody be left on the curb.Report

      • Avatar zic says:

        My recommended plan includes the freedom of a notarized opt out. I agree the premium would need to increase for each year uninsured if they later decide to join.


      • Avatar roger says:

        Still not following you. Are you suggesting that providing the freedom of a person to opt out of a subsidized universal catastrophe care system (where poor people pay little or nothing) reflects a ridiculously narrow emphasis on freedom?

        Again, everyone still gets catastrophe care. They just become responsible to pay for it if they opt out. Have you actually spent any time considering the pros and cons of the recommendation? I sense you are just doing a rush to judgment.

        Please list out the pros and cons. What you like and dislike about it? Ask yourself which would actually protect the most people the least expensively, my suggestion or Obamacare. I am not saying you must agree, but at least give it a fair shake.Report

      • Avatar BlaiseP says:

        While opt-out remains on the table and EMTALA remains law, you’ve pre-scuttled your own ship before you got it out of the ways.Report

      • Avatar zic says:

        Roger, I have children in their 20’s, and know lots of people in that age bracket. I know they think they’re invincible, they’re strong and happy to take physical risks.

        For many people in this age bracket, there is little in the way for employment for them; the work there is often pays horribly, and insurance is not provided. There’s inability to pay rent, let alone shoulder a health insurance plan.

        You give them the choice of opting out, and they will. With your first comment, which I quoted above, you did not provide a catastrophic provision; you said opt out. So first off, we’re discussing a shifting field.

        But with catastrophic coverage emerging for everyone, we start to get to some form of government-provided universal care at some minimal level; you’d just take that 20-something year old, and take it out of his pocket for the remainder of his days, seriously hampering is ability to pay back his college loans, let alone ever buy a house or have a family.

        Your view of his life only considers his economic ‘rights’ in the moment, with a focus of keeping his choices from lightening your pocket. I think you would benefit from turning that around and considering how that underlying system could better increase his earning potential.

        But that’s what he’s supposed to do with his bootstraps, right?Report

      • Avatar roger says:


        That is why I laid out my full recommendation below… Every point you are making shows me that you are arguing with a plan that is 180 degrees from what I am actually suggesting.

        Read below please. Thanks.Report

      • Avatar Kim says:

        Roger is ALWAYS for subsidizing the poor.
        Hence my comment upthread.

        I however, do think that insurance is a better plan than opting out.
        I suspect Roger also believes that, and would tilt the game so that would
        be always true.Report

      • Avatar Patrick says:

        You give them the choice of opting out, and they will.

        Unless/until we actually decouple employment from insurance, I think the vast majority of them will not. I didn’t know that many folks who opted out of insurance coverage from their employer even when I was younger.Report

      • Avatar Patrick says:

        Although Tod’s current post is making me rethink this last comment. I… need… data…..aaaaaahReport

      • Avatar zic says:

        @patrick, here’s a start on that data.

        and WSJ on folks who turn down employer-offered insurance.Report

    • Avatar roger says:

      Just to clarify here is a cut and paste of my recommendations for comprehensive reform…

      1) I would recommend exploring ways to establish catastrophic care for extremely serious and expensive medical conditions. I would allow people to opt out of this with some very onerous requirements. This would be paid for via payroll taxes unless the fool opted out.
      2) I would recommend people buy their own insurance that meets their needs for routine, non catastrophic care. I would choose a high deductible and low premiums and few frills. Others can get low deductibles, high premiums and all the frills they would like. I would allow any company to sell any policy that people will buy as long as the company is honest and has proper reserves.
      3). I would encourage experimentation with guaranteed insurability and portability, so that people would not be harmed on their routine care premiums if their health status changed.
      4). I would subsidize the poor and elderly and possibly the sickly so that they could purchase the underlying coverage policy and pay their deductibles. Catastrophe coverage would be free or cheap as they do not work much or at all.

      I would add choice, competition, experimentation and all that wherever possible, and if this doesn’t work, I would just follow Singapore’s model.Report

  4. Avatar Vikram Bath says:

    One: [Tommy pays higher premiums for having joined later.]

    Well, higher premiums resulting from young people not being in the system is exactly the problem that the mandate is trying to avoid. The assumption is that those higher premiums would be too onerous for the set of people that Obamacare is supposed to affect in the first place.

    Two: [Tommy’s $500k of care gets garnished from his wages till the end of time.]

    This sucks for Tommy. You can say that that is tough luck for him, and he knowingly took the risk. It does indeed solve the free-rider problem, but to my best guess those who support Obamacare would be deeply unhappy with a solution that results in someone having to pay off $500k of medical bills themselves. The whole point is to avoid that ever happening to anyone (other than an insurance company or the government).

    Three: [Tommy gets cancer and doesn’t get care.]

    Again, this is an option that does not involve the free-rider problems, but it isn’t what the framers intended.

    And don’t forget that there is a fourth:
    Four: Tommy never gets sick, but pays premiums or penalties for not having insurance.

    This leaves Tommy, with no value for what he’s paid, but that is the way insurance works. Insurance needs a lot of people to be in this category.Report

    • Avatar Burt Likko says:

      Scenario four — as an actuarial matter, it seems safe to say that if Tommy Boy never gets sick, he’s a statistical anomaly. We can safely ignore him from a policymaking standpoint. Disclaimer: I am not an underwriter to know this for sure. But come on.Report

      • Avatar Vikram Bath says:

        Tommy is young and has no known health conditions going in. It is certainly possible for him to go a year without having to visit a doctor.

        That said, we can relax this case to read instead: “Tommy rarely gets sick, but pays more in premiums or penalties for not having insurance than he receives in care.” In other words, Tommy contributes more than he gets.Report

      • Avatar BlaiseP says:

        Tommy is getting coverage. Without insurance, capitalism and the rise of the merchant states would not have been possible. No sailor wants his ship to sink and will do everything to prevent it. But no merchant will put his goods aboard that ship without some recourse if the ship does sink.

        Tommy Boy’s not paying for health care. The insurer pays. Tommy Boy is paying today so he DOESN’T have to declare bankruptcy later.Report

      • Avatar Burt Likko says:

        Conceded that Tommy Boy is actually pretty likely not to get sick this year. But only thinking about this year and not thinking about future years is part of how relying largely on unregulated markets gets us in to long-term economic trouble, no? Left to its own devices, the free market isn’t all that good (I didn’t say utterly incompetent) about long-term thinking and planning, and tends to suffer paralysis when confronted with a “choose-the-least-bad” rather than “optimal-equilibrium-available” set of options because individual actors within the free market tend to find forebearance from gratification to be too risky (“If I do without utility now, then conditions might change and I’ll also have to do without utility tomorrow, too. If I take now, at least I have utility today.”)Report

      • Avatar BlaiseP says:

        Insofar as a market is free, it has sufficiently reliable information to operate. While health insurance won’t expose the real numbers — and concurrently, while the health care providers are not subject to market pressures — we shall have no free market.Report

      • Avatar Burt Likko says:

        Fair enough, @blaisep , but doesn’t that mean that there has never been a free market for either health care or health insurance?Report

        • Nob Akimoto Nob Akimoto says:

          I think the main problem is that the current US health care infrastructure is pretty much the result of health insurance being structured the way it was in the 40s and 50s. Specifically the hospital and care structures we have today are largely built on the back of widespread employer provided insurance. Remember it wasn’t until the mid-20th century that most people ever even saw a hospital, much less used it for most of their medical care needs as they do today.

          Surely there’s been a free market for it, but that’s like comparing the market for attorneys in colonial new england with modern law practices.Report

      • Avatar BlaiseP says:

        Hard to say if there’s ever been a meaningful market in health care in modern times. It’s like baseball, all driven by statistics. Before sulfa drugs and effective anesthesia, medicine was mostly mumbo-jumbo so the comparisons fail pretty quickly.Report

      • Avatar BlaiseP says:

        As for markets in health insurance as we understand it today, it arose as a way to give workers a raise while salaries were capped. The rest is the creation of the tax code and the state regulators. Surprisingly little federal oversight of the process.Report

    • Avatar Shazbot9 says:

      Great comment Vikram.

      This is exactly right.

      I think the case for the mandate is not a moral one of saying that a.) those that don’t get insurance deserve to be punished for their risky behavior and b.) everyone should pay their own way on their insurance because it intrinsically good for people to pay their own way. (This is how Heritage and Romney framed the mandate when they proposed it, IIRC, but that is conservative rhetoric that Obama sometimes bought into after the primaries.)

      Rather, the case for the mandate (which is really just a tax credit, to incentivize getting health insurance, as I discussed with Kazzy) is that we need insurance that socializes the costs associated with the risk of healthcare, and it will only do so if almost everyone has it. (Otherwise you get what Cohn and Gruber call the “death spiral” where the healthy opt out of the pool of insured, increasing costs for the remaining insured, causing more to drop out, and so on, until you have a pool that is very sick who buy incredibly expensive insurance that few can afford.)

      If you wanted insurance that didn’t socialize the costs associated with illness and the risk of getting ill, that left a sizable percentage of the population to pay their own way, you’ve got serious economic and social and moral problems in society. We don’t tolerate that, so we bring in a touch of socialism. We just do. And that is good.

      Conservatives and libertarians may not like this but it is good and necessary that we socialize the costs of health care and the risk of needing healthcare.Report

      • Avatar DavidTC says:

        Conservatives and libertarians may not like [the mandate] but it is good and necessary that we socialize the costs of health care and the risk of needing healthcare.

        Conservatives liked it just fine. It was their idea.

        Also, having the government require people to purchase things may be an overreach of government powers and/or might be a bad idea, (Not that I think so), but the one thing it really can’t be called is any form of socialism.

        Socialism is the exact opposite concept, where the government produces the things (Aka, operates the means of productions) that people voluntarily buy. The government saying ‘You must buy X from private businesses’ is, if any political ideology, in the direction of ‘fascism’.

        Please note that I don’t think it’s actually ‘fascism’, anymore than the I think the government building and operating a toll road is ‘socialism’. I just find it really weird some people in this world have decided to call ‘The government forcing the purchase of stuff from private individuals’ ‘socialism’, when it is literally the opposite of that concept.

        In ‘socialized medicine’, the government would be producing and selling health care, and it would be paid for by private individuals. And if the government produced it and then gave it away, that would be ‘communism’. (Of course, it wouldn’t actually, as those terms describe entire economic systems, not interference in individual markets…the government providing free roads to everyone, for example, does not make our entire economic system ‘communism’.)Report

  5. Avatar LeeEsq says:

    I find all of these ethicallly problematic and Scenario Two completely unworkable. For the majority of people, $500,000 is a lot of money to pay off and there is a good chance that most will never be able to pay it off completely. How do you determine how much wages to garnish? If you garnish too much, Tommy Boy is going to have problems living an ordinary life and will need even more help. If you garnish too little, the debt never gets paid.Report

    • Avatar Kim says:

      $500,000 is essentially one house.
      You have just changed one “owner” into a “renter”, who is paying all of his rent to the government.Report

    • Avatar Shazbot9 says:

      Yeah the tax garnish that Tommy gets hit with would have to be structured to incentivize people to buy insurance so as not to end up like Tommy but not be so onerous as to ruin Tommy’s life. Maybe 2.5% of his income or something.Report

      • Avatar Troublesome Frog says:

        2.5% of income pretty much leaves society holding the bag for Tommy’s care unless Tommy makes serious money. In fact, for a life saving treatment, I’d say that 2.5% is a pretty sweet deal.

        You’d really need to stick it to Tommy. His alternative was being dead, so as long as he has enough of an incentive to keep working, you’re not charging him too much.Report

      • Avatar Shazbot11 says:

        Yeah, a 2.5% penalty for not buying insurance is not onerous. It is just a small tax incentive.

        Of course this means that the mandate (2.5% when it fully ramps up in a couple of years) is not onerous either.Report

      • Avatar Troublesome Frog says:

        There’s a major difference between a guaranteed 2.5% penalty every year and a small chance of a 2.5% penalty starting at some point in the potentially distant future.Report

      • Avatar Shazbot11 says:

        I take it that your position was that a lifetime of paying 2.5% (which would likely not add up to $500,000) was not onerous for Tommy Boy.

        So a lifetime of paying 2.5% is not onerous for Bill The Insurance-Phobic Yuppietarian either.Report

  6. Avatar Kazzy says:

    Regarding the $500K, I’d want to know how much of that is actually the expense of providing treatment and how much of that is markup and/or other costs.

    As has been discussed elsewhere, there is often a big gap between the sticker price on a given procedure and what is typically paid by insurance. And while I’m sure all care providers would prefer the former, I doubt the latter figures are going to put any of them out of business. And we could even say that if wage garnishment is required, it will be at a lower figure still (perhaps at cost); a bit of a progressive scheme built in.

    I’m sure it is possible to rack up $500K in medical bills, but I think when those lofty figures are thrown out there, they tend to include incredible markups (some of which, I’m sure, is required to offset the losses typically taken on non-paying patients, which this system would theoretically eliminate).Report

  7. Avatar Burt Likko says:

    Without Obamacare, if Tommy Boy goes bare and suffers a catastrophic injury or cancer, he still winds up getting care anyway, either as a charity case, as a write-off, or as a bankrupt. Or not, and then he wastes away, homeless, and dies below a freeway overpass.

    Obamacare is far from perfect. FAR from perfect. But it’s surely less bad than any of the above results.

    My principal concern about Obamacare is that after the bureaucracy and technical language is lifted, it reduces down to a Federal subsidy for mandatory minimum health care that appears to be underfunded through the tax supports built in to the “penalty.” Maybe the math will work out that it is really revenue-neutral, but I remain unconvinced and it’s really a matter of faith in what economists project. Until experience proves otherwise, my assumption (based as much on faith as the contrary opinion) is that it will increase the deficit and thus the debt.

    But it’s no assault on freedom to require people to have health insurance. It’s a statement of our national wealth and compassion that we provide at least minimal coverage to everyone, and it’s a damn shame that a nation as wealthy as ours hasn’t done it up until now.

    Oh, and to answer your basic question, Pat — it doesn’t matter what the problem is or what the fix is because the problem is optical rather than substantive. There will always be an objection to Obamacare that is presented in the form of an existential threat to all that is good about America. Because to the objectors, Obama himself is an existential threat to all that is good about America, and therefore anything associated with him is, too. If a Republican takes the White House again, then superficial regulatory modifications to PPACA will become the foundation for “saving” the country from PPACA and Republicans will like it just fine.

    …But you knew that already.Report

    • Avatar zic says:


      Has anyone looked at the Issa plan? Obamacare, without the Obama in it.

      And more-generous subsidies, to boot.Report

      • Avatar Kazzy says:

        “Obamacare, without the Obama in it.”

        Well, that would just be “care”. There is no room for “care” in our political -OR- medical system, @zic .Report

      • Avatar BlaiseP says:

        Issa is fuller of shit than a Christmas goose. The GOP (and by proxy, their pimps in the health insurance industry) got everything it wanted in the Obamacare bill, to the point where the government has run everyone into their market space, willy-nilly.

        The Tea Parties don’t want anything of this sort. They know it’s Moah Gummint. They don’t care if it solves a problem or not. They don’t want the government to manage this — or any other — process. It’s all very stupid of course, health care is a problem everyone has. Notwithstanding the obvious, that Obamacare is a great windfall of profit for the private sector, they won’t have any of it.Report

    • Avatar Kim says:

      “If a Republican takes the White House again, then superficial regulatory modifications to PPACA will become the foundation for “saving” the country from PPACA and Republicans will like it just fine.”

      … the vast rightwing conspiracy (and the Kochs too, of course) are playing a different game now.
      Please pay more attention, the situation grows serious.Report

    • Avatar Michael Drew says:

      There’s way more by way of taxes in Obamacare than the personal responsibility penalty, though outside of the 10-year window starting in 2010, AFAIK serious people don’t deny that it costs more money than it brings in or saves (compared to 2010 health cost projections) for a considerable period of time (people who just say ‘Obamacare reduces the deficit!!1!’ without that caveat being unserious people). It would do that until such time as the cost-controlling measures it initiates start to bear real fruit and alter the baseline health costs in a way that wouldn’t have happened without those measures. Recall that there was in 2009 theoretically a huge long-term health-cost deficit facing the federal government and states; compared to that baseline Obamacare could in the long term reduce the size of that health cost burden on the federal government by more than its ongoing additional spending on public coverage and coverage subsidies minus the taxes that are part of the law – all while a huge health-cost deficit facing the federal government persists (such is the size of that theoretically projected cost overrun from 2009). In the long term, I don’t think that the Obamacare cost-saving measures are anything to sneeze at. Of course, maybe we’ll repeal it before we get to the long term, who knows.Report

      • Avatar Kim says:

        Paperless offices would save tons of money. Obamacare incentivizes them.Report

      • Avatar BlaiseP says:

        Please. Obamacare has not done anything to standardise the health care claims process. That was thrown overboard very early when Single Payer was taken off the table. Paperless offices — eet eez to larf. The continuing madness of HIPAA 5010 compliance and FRSS rules still govern the process.Report

      • Avatar Kim says:

        that’s on the payer side. I’m speaking on the provider side, in terms of dataexchanges to help take care of the patient. Do you know how much it costs to fax around medical documents? Let alone pull medical records, in a paper office?
        ACO’s, Electronic Health Records, ClinicalConnect (making hospitals’ data interoperable).Report

      • Avatar BlaiseP says:

        Do I know about the associated costs? Few better, Kim. The current rules for Medicare and associated state plans mean little providers still fax in 1500 forms instead of sending 837P EDI. Oh, you could send in 837P if you’ve got the IT staff and programmers to support it. Most little guys don’t. Debugging a bad ST stanza is beyond most of these outfits and the entire transaction is rejected, with some mysterious 997 response. Oh, do I know about the Associated Costs.

        Moah Technology is not the solution. Consistent solutions are still to be preferred. Obamacare has not provided them.Report

      • Avatar Kim says:

        you’re still speaking about payer/provider interface. I’m talking about provider/provider interface. Please, address the points that I’m making.Report

      • Avatar BlaiseP says:

        Kim, I am addressing the Number One problem with health care today, getting paid. I am outlining the process of Getting Paid. It’s a nightmare on the provider end. It’s contributed to the astonishing rise in health care costs as nothing else has. But it’s been awfully good for the insurance firms, who get to nit-pick the claims, reject them out of hand, delay payments, short-pay, screw over the provider — then, with supremest gall, offer him a more efficient process if he’ll go PPO, thus capturing his practice. This is bullshit.

        You’re just diddling around, thinking health care is like those adverts for some whizbang technology, with some Smart Guy pointing at the monitor, with the cute girl and the avuncular exec looking admiringly over his shoulder. Tech is not the solution. Anyone who thinks tech is the solution to the problems of health care is either an idiot or doesn’t understand the process.Report

      • Avatar BlaiseP says:

        As for provider/provider interfaces, there’s been a recent invention which addresses this problem. The telephone. A GP can, and routinely will, call up the appropriate specialist and send his patient round for another consult.Report

      • Avatar Kim says:

        Oh, no arguments there. The payer/provider interface is indeed a nightmare, and indeed deliberately so.
        I’m merely arguing that Obamacare does actually have some decent provisions that will reduce waste (and yes, paying someone to fax over the x-rays is waste, just like having the doctor use the telephone).Report

      • Avatar BlaiseP says:

        I say Obamacare hasn’t paid a lick of attention to the people who have the problems: the physicians, clinics and hospitals. This discussion has been dominated by the Purveyors of Expensive Whizbang and Obamacare has addressed none of the fundamental issues facing American health care providers today. I have been part of these discussions since the early 1990s. I know the players. I consult for the largest of them. They got everything they wanted — and more — out of the process. And nobody, NOBODY paid any attention to either the physicians or the hospitals.Report

      • Avatar BlaiseP says:

        I would argue the telephone is the most appropriate technology for physician-to-physician contact. It has certain useful advantages:

        1. Need to know data is kept confidential. Well, maybe the NSA is listening in. But it’s not going through some craptastic, insecure web service.

        2. It minimises data transmission. The two physicians, if they’re competent, will only ask the relevant questions. None of that information can be transmitted in a standard format. Optimally efficient, too.

        3. It routes optimally. GP uncovers an osteosarcoma, knows the right orthopaedic surgeon, the orthopaedic surgeon knows the right onco guy, problem solved.Report

      • Avatar Kim says:

        for somethings, yes. Allergies, interdrug relationships, no. Why should your ER doc have to wake up your PCP to ask what drugs you’re taking? That could already be in the system, along with a decent diagnosis of what your chronic problems are (thus helping distinguish anaphylactic shock from stroke, for example).Report

      • Avatar BlaiseP says:

        Who’s going to write up the WSDL for that web service, Kim? It would take a heavyweight, conformal web service with supporting data layers to provide it. And who’s going to administer security on it? HIPAA et al. hasn’t even addressed grantable and revokable certs for physicians and pharmacists. Obamacare hasn’t provided for any of this. Big Pharma hasn’t provided a spec, though it’s constantly talking about it. HIPAA hasn’t provided for any such mechanism.

        Don’t aggravate me, Kimmie. To get to where you want this process to go would take monumental and politically unpalatable, probably unconstitutional changes to identity management in this country. We can’t even get standards for voter registration.Report

      • Avatar BlaiseP says:

        There’s a reason the fax machine is still in operation: accountability is still achieved via Wet Ink. Without a signature, prescriptions don’t get filled.Report

      • Avatar Kim says:

        Hipaa doesn’t need to. Anything that can be called “pursuant to patient care” can be passed around without legal consequence. (of course, you do need to document who’s accessing stuff, that way if they’re doing it when they shouldn’t…)

        The lawyers in Congress wisely leave the setting of standards to techs.

        As to who is going to write the WSDL? We already have.

      • Avatar BlaiseP says:

        Heh. Maybe you ought to read your own privacy page. And I don’t see that WSDL out in the open. Got a URI for that one, so I can turn out a SOAP envelope for it?Report

      • Avatar BlaiseP says:

        And you might want to fix your links to HIMSS on the Providers page. They’re currently broken.Report

      • Avatar Kim says:

        not my codebase. my organization, not my work.
        (though i’ll note Obamacare highly incentivizes this sort of stuff)
        and… I don’t fix website links.Report

      • Avatar BlaiseP says:

        Heh. Don’t let your mouth outrun your ass, Kim. You said some “We” entity had already written the WSDL. If this is true, that you have indeed written an encompassing WSDL-based web service, where is its URL?

        Here’s what a WSDL looks like: were your solution in place, you could easily furnish the link to that definition. Now what I can say, for a fact, is this: anyone wanting access to that URI would have to execute a contract with your outfit. Hardly an open standard likely to go anywhere.

        Here’s a little something I had a hand in composing. Here’s another. This is the real world, Kim. There is no interoperable standard beyond HIPAA 5010 at this point and no two entities parse these EDI datasets the same way or according to a common set of rules. All they have to do is pass muster by the two trading partners and every last one of those partners is either completely intransigent by virtue of technology lock-in or by particulars of implementation.Report

  8. Avatar morat20 says:

    Doesn’t work unless Tommy can pay 500k over his lifetime (with interest). Which may or may not be the case.

    That doesn’t factor in mortality rates either — say Tommy’s accident costs 500k. A man suffering Tommy’s injuries has an 70% chance of a full recovery, a 20% chance of mostly full recovery (say, sans a limb), and a 10% chance of dying somewhere between the accident and exiting the ICU. (Surgery gone wrong, etc).

    Now Dead Tommy’s (1 out of 10) might only rack up, say, 100k in bills due to dying so early. But that’s 100k a dead man doesn’t pay. He was a free-rider, and thus had a 90% chance of a full recovery — but his odds came up bad, and society’s on the hook for 100k.

    Catastrophic cases are rarely cases in which an individual will EVER be able to pay off the costs, not even over a full 50 years of work. (Not if they want to eat and have a roof over their heads). Free rider that, and society is STILL on the hook for the bulk of the costs.

    Can’t get blood from a stone. Especially a dead one.Report

  9. Avatar LWA says:

    The occasional catastrophic accident is actually rare enough to where almost any system can absorb it, in a large nation.
    So we could propose all manner of systems to contend with that.
    What requires more effort is the inevitable health care needs of the aging. Very few people can pay their own way in later life.
    The senior years are too long, the illnesses too chronic, the treatments too expensive, to have anyone actually pay cash for their treatment. Insurance only works because of the aforementioned Tommies.

    Seniors COULD pay their own way- IF we shift to a society in which virtually every penny of savings in your younger years is zealously hoarded away for the possibility of a health decline in your old age.

    My question regarding all the “opt out” scenarios is, why is opting out important?
    Why is this valued over the stability and security of a society in which health care is easily available?Report

    • Avatar Patrick says:

      My question regarding all the “opt out” scenarios is, why is opting out important?
      Why is this valued over the stability and security of a society in which health care is easily available?

      I fully expect that after N years, nobody would opt out. There’d be a couple of Tommys who would wind up testifying in House committees, tearful about how they were stuck with a debt load larger than the one they had been carrying for college, and some Congresscritters would make a number of speeches about how horrible the IRS is and how this must be stopped, and the problem would basically solve itself.

      To answer your question, though, right now we have a basic stability and security problem, right? Which is getting worse the closer we get to the 17th?

      I think you’ve set up a false dichotomy. I don’t think this is an exchange between “freedom!” and “safety!”Report

    • Avatar roger says:

      Thanks for addressing Morat’s point.

      The reason I recommend opt outs is because..
      1) Some people do value freedom.
      2) The nature of the tradeoffs is such that someone would be crazy to choose an opt out. Who would opt out of a subsidized -for- the-working poor, free to the non-working program with automatic withdrawal and penalties if joining later?
      3). If people do begin to opt out, it would be because the system is being jury rigged to exploit some subclass of members. The opt out mechanism thus becomes a feedback system to disincentivize exploitation and privilege getting cooked into the system. In other words,


      So, I throw the question back at you… Why would you have a problem with opt outs on a subsidized system which provides universal care? I thought you were a big fan of consensus and democracy. If a rare opt out provision made the system palatable, why would you throw out the baby with what you perceive as bath water (and others as champagne)?Report

      • Avatar BlaiseP says:

        Opt-out doesn’t keep the game honest. It keeps the game crooked. Freedom to statistically defraud the public, freedom to collude and fix prices, freedom to capture the providers into vertical markets, freedom to override diagnoses and treatments, systematically undermining every principle of probability and reality.

        And here I thought you knew something about the nature of insurance.Report

      • Avatar Kim says:

        “If people do begin to opt out, it would be because the system is being jury rigged to exploit some subclass of members.”

        … this assumes honesty and not stupidity is the motivation for opting out.

        Is it opting for gain, or stupidity, that makes folks cheer the possible US debt default? I’d contend mostly stupidity and effective advertising.Report

      • Avatar Patrick says:

        Blaise, I’m pretty sure the game is crooked and will continue to be crooked until the human race is all over and done with.

        The UK system undoubtedly has fraud in it, just like Medicare does. The question is, how much and how well is it contained.

        I really, really doubt you’d see more than 10% consider an opt-out strategy, and I really, really expect that most of them would opt into the system fairly seamlessly (paying a higher vigorish for the foolishness of their youth).

        And yes, under this system, some dumbass is going to get the catastrophic care he needs, and he’ll have a huge bill tacked onto his IRS account, and he’ll still be denied a number of non-life saving, life-quality necessary procedures, and we’ll have to deal with that problem separately.

        I think that’s a solvable problem.Report

      • Avatar Kim says:

        10% is below the #panetta-burns threshhold, isn’t it?
        I’d say 45% as a maximum, and that’s if the Vast right wing conspiracy (and allies) roll with their plan to bankrupt obamacare.Report

      • Avatar BlaiseP says:

        Health Insurance as we know it wouldn’t pass muster by the Las Vegas Gaming Commission. It’s a rigged game with the insurer not only holding all the cards — he won’t even put those cards on the table.Report

      • Avatar LWA says:

        But no one is actually proposing a system where someone can truly opt out of the entire system; that is, refuse to pay, and not receive the service.

        All the propositions are careful to assert that a person opting out would still receive the service, although in slightly reduced fashion at a more expensive rate.
        This isn’t opting out, this is encouraging irresponsibility.

        Like it or not, we have created a society in which refusal of medical care is not allowed, full stop. No one has the freedom to choose such a society, at least not in the 1st World.
        So we can only find efficient ways of getting everyone to contribute, like it or not.Report

      • Avatar Troublesome Frog says:

        If people do begin to opt out, it would be because the system is being jury rigged to exploit some subclass of members.

        That assumes that nobody is opting out because they’ve found a genuine way to free ride. The incentives of such a system would have to be set up very carefully, and I’m not convinced that these proposals would do the trick. In fact, I’m pretty certain that it would be a real nightmare to make those numbers work.

        Certainly, if we have a system that is bulletproof against free riders, I’d be all for eliminating the mandate. It only exists because of the free rider problem. It’s not like we just enjoy slapping mandates on people for kicks. That’s just cartoonish and ridiculous.Report

      • Avatar morat20 says:

        How do you “opt out” of health care?

        Seriously, given the way health care works in the US — how do you opt out? Let’s ignore the slower ones (let’s pretend, for the moment, that someone facing cancer or injury that can be cured, if he could afford it, would decide to die or live crippled rather than be a burden on society — which is a choice I suspect most of those screaming FREEDOM would not actually take) — just the catastrophic emergencies.

        You collapse. Or you’re in a car wreck. How does the health care system KNOW not to treat you unless you can afford it? How can they even tell?

        “Opting out” of receiving health care doesn’t actually seem possible. If you’re unconscious, bleeding in the wreck of a car — they will cut you out of the car, take you to a hospital, and try to fix you. Your “opting out” doesn’t come up, because you’re too injured or sick to do so.

        So really “opting out” seems to mean “I’ll take the risk society will end up on the hook for my bills, which I totally think I won’t ever generate and thus will ignore the fact that there is an actual risk I will”.Report

      • Avatar Patrick says:

        You collapse. Or you’re in a car wreck. How does the health care system KNOW not to treat you unless you can afford it? How can they even tell?

        They can’t, not with any reasonable amount of surety. Indeed, we wouldn’t like any attempt to implement such a system, because (as I’ve mentioned before), any system that would be built to verify insurance possession would have holes in it, and the result is that some people with coverage would not be admitted, and would die unjustly.

        You can opt out to an extent, however. You can opt out of being treated like an adult, by refusing to act like one.

        If an ambulance rolls and picks you up and they deliver you to an emergency room and you get stabilized and then the record comes down, “Joe doesn’t have insurance”, the ticker starts and when the patient is stable enough to leave the hospital, the hospital sends the bill to the Federales and it’s up to the government to get the money back. And nobody provides any more care for the guy until he can pay for it.

        Yes, there will be some distortions here. Some of that money won’t come back into the system, because some people will incur lifesaving care that is expanded beyond their ability to ever pay it back. But I don’t think this will be the majority of cases; usually the money starts going up as the treatment extends past a couple of days. Nobody says the hospital needs to give you cosmetic reconstruction surgery or months of physical therapy.

        Look, here’s the rub.

        Some people don’t want what’s good for them. They don’t want it so badly that they are currently all cheering – cheering! – the absence of a function government because they very badly want to act nothing like the conservatives they claim to be.

        So fine. Give them what they want. You don’t want insurance, don’t get it. You will, ultimately, eventually, bear the lion’s share of the cost of that decision. Sign here.

        Ten years from now, when these idiots are humbled by their own actions into admitting that maybe, yes, they were effin’ stupid, then we can revisit helping them out.

        This is, apparently, a lesson they’re going to have to learn on their own.Report

      • Avatar greginak says:

        What about bankruptcy? If Tommy Boy piles up big medical bills but can’t pay them can he just tile for bankruptcy? If not why? If he can then that does give him an out, although one with some costs, instead of paying a few hundred grand.Report

      • Avatar BlaiseP says:

        Here’s how it’s really going to play out. Medical bills are the leading causes of bankruptcy in this country. Nobody’s going to get paid. Prices have already distorted around this problem.Report

      • Avatar Patrick says:

        My understanding is that you can’t get rid of debt to the government with bankruptcy. (my understanding may very well be wrong).Report

      • Avatar BlaiseP says:

        Heh. It’s good to be king.Report

      • Avatar morat20 says:

        So fine. Give them what they want. You don’t want insurance, don’t get it. You will, ultimately, eventually, bear the lion’s share of the cost of that decision. Sign here.

        Yes but their freedom to “opt out” is called “Sticking me with the bill”. What about MY freedom not to be billed for their stupidity?

        All those Tommy’s add up, and while their individual risk of running up an unmanageable debt is low, their collective risk is enough to flat out guarantee society will be eating a LOT of losses.

        So it comes down to conflicting rights — and the guys opting out are basically saying “My right to free-load is SO IMPORTANT I can make you pay for it”.

        And, you know, they do. Which is what the “freedom to opt out” argument is missing. They’re not actually going to pay for their risk. I, and everyone else participating, will be. What about our rights, our freedoms?

        If Tommy is gonna be on the hook for debt he can’t pay that I’ll have to cover, the least he can do is pay a token fee.Report

      • Avatar Patrick says:

        Yes but their freedom to “opt out” is called “Sticking me with the bill”. What about MY freedom not to be billed for their stupidity?

        No, they’re stuck with the bill. The lion’s share of it, for a long time.

        Again, yes, some small percentage of them will incur a massive amount of expenditure in a week such that they could never possibly pay it all back – this is not the norm. The norm, for some percentage of the opt-outers, probably not a great percentage of them actually, because I contend most of them would eventually opt-in… would be a fairly large long-term obligation to Uncle Sammy, akin to what they’re carrying now in college loan debt.

        Some other percentage of them will incur a large expense, and will be denied extended care because they won’t be able to pay *that* back. So they’ll have a degraded quality of life. Well, life is hard. They chose not to wear a helmet. The needs of the many outweigh the needs of the few, or the one.

        It is at this point premature to say how many of these people there actually are, what their costs will be, how many of them will incur a big tax burden, what the long-term implications are for all of that, sure.

        Uncertainty is a factor. Uncertainty is a factor with Obamacare, too. Changes will undoubtedly need to be made in five years or ten.

        I imagine the conservatives – the actual, real conservatives – will be the ones pushing for a mandate in five years or ten, if we need one. So they got some time, and they came around, and we can move forward.

        What’s the drawback? Some number of idiots bear a huge cost for their idiocy. This could also be regarded as a win.Report

      • Avatar BlaiseP says:

        Well, you know, prisoners get health care and dental and vision. People on the street don’t.Report

      • Avatar Burt Likko says:

        An obvious inequity, @blaisep , remedied by the obvious solution of requiring prisoners to pay for their own medical care like everybody else.Report

      • Avatar morat20 says:

        Again, yes, some small percentage of them will incur a massive amount of expenditure in a week such that they could never possibly pay it all back – this is not the norm.

        Oh, I see your trouble. You think the problem is Tommy. No, the problem isn’t Tommy. It’s ALL the Tommy’s. Collectively. Outsized bills they can’t pay are actually more common than you think, but I don’t give two flips for Tommy personally.

        I worry about the class of Tommy’s, where only one in ten thousand might rack up, say, a million dollar bill they can’t pay and thus I have to — but if there are 10 million Tommys, that adds up.

        And Tommy’s individual freedom, when summed over 10 million Tommys, picks my pocket.

        Tommy himself might just be picking my pocket to a fraction of the cost of a catastrophic policy, but him and all his fellow travelers are reaching into the elbow and whining about their “Freedom” being infringed when I tell them to stop it.Report

      • Avatar Patrick says:

        only one in ten thousand might rack up, say, a million dollar bill they can’t pay

        Er, 310 million people divided by 10 thousand times 1 million equals $31,000,000,000.

        I’m aware that we pay more for health care than we ought, but I don’t think $31 billion of it comes from that source.

        Granted, depending upon the amounts and the cost-shifting, this maybe might be a problem. But it also might be noise.

        I’m not sure which it is, but you seem to be pretty confident that it’s a problem and not noise. Aside from gut feel, you have any particular reason?Report

      • Avatar roger says:

        You guys are not giving any thought to the issue of “how can I structure the opt out in such a way to discourage stupidity and free riding?”

        One well known solution in other insurance is to require the person opting out to provide a bond or proof of other insurance. If you guys brainstormed on the issue I am sure you could come up with several dozen other ideas.Report

        • Nob Akimoto Nob Akimoto says:

          Given that this is already done for a lot of university students (foreign ones, mostly), it doesn’t seem like it’d be all that difficult a thing to do.

          F-1 students are all required to have health insurance either through the university or present proof of an alternative (like one provided by their home government). Presumably this is to prevent free-riding and underestimating risk on the US healthcare system.Report

      • Avatar Troublesome Frog says:

        One well known solution in other insurance is to require the person opting out to provide a bond or proof of other insurance.

        I’m fine with those solutions. I’m just a little surprised to hear it floated as something other than an assault on individual autonomy, and I don’t really see how those two options don’t basically boil down to “you need to buy insurance.”Report

      • Avatar James says:

        How do you “opt out” of health care?

        Seriously, given the way health care works in the US — how do you opt out? Let’s ignore the slower ones (let’s pretend, for the moment, that someone facing cancer or injury that can be cured, if he could afford it, would decide to die or live crippled rather than be a burden on society — which is a choice I suspect most of those screaming FREEDOM would not actually take) — just the catastrophic emergencies.

        You collapse. Or you’re in a car wreck. How does the health care system KNOW not to treat you unless you can afford it? How can they even tell?

        “Opting out” of receiving health care doesn’t actually seem possible. If you’re unconscious, bleeding in the wreck of a car — they will cut you out of the car, take you to a hospital, and try to fix you. Your “opting out” doesn’t come up, because you’re too injured or sick to do so.

        So really “opting out” seems to mean “I’ll take the risk society will end up on the hook for my bills, which I totally think I won’t ever generate and thus will ignore the fact that there is an actual risk I will”.

        I think the major objection to the individual mandate–my very strong personal objection, for what it’s worth–is the combination of the mandate to have insurance on the individual AND the list as long as my arm of mandates on insurers that has driven / will drive premium costs through the roof.

        You brushed it off in your first paragraph (“Let’s ignore cancer for a minute and focus on accidents”) because it makes your argument tidier. And indeed if that’s what we were facing with the PPACA, I personally wouldn’t object to the mandate. I can get catastrophic care for $34/month. Voila, you don’t have to foot the bill for my accident.

        But now the laundry list of mandates on insurers–all the bells and whistles that the government has decided have to be “covered” (along with the level that defines “covered)–mean that I can’t get that product anymore. If I can, it’s not good enough for the government and I’m still subject to their fines. Now, to be legal, I need to get a product I have absolutely no use for–a pre-paid medical services plan. NOT “insurance” as properly understood.

        I am one of those folks who would say, “OK, it’s my time” if I had a cancer diagnosis. You wouldn’t get stuck with my bill. I certainly won’t ever make use of the several-dozen other medical-coding-defined products and services that are now mandated to be a part of a product that I’m mandated to buy.

        I don’t want to be a “free rider.” I don’t want to stick you with my bills. I just don’t want to have your government stripping 10% of my living money away from me from now ’til I meet my maker just because it helps make MRI’s and all the fancy bells and whistles of western medicine slightly cheaper for you or others who do choose to partake in that.

        *Final point: long-time reader, first-time poster. I guess I may need to create an account or something, and I hope that this reply a) shows up near the right spot and b) is formatted decently. Thank you to all for your thoughts and making for a wonderful haven on the ‘net.Report

      • Avatar Roger says:

        I think the burden of proof is on those using the threat of coercive force in mandating insurance. Hence the reasonableness of trying to to do opt outs if practical

        While driving today I thought of about a dozen alternative ideas. I fail to grasp why anyone fears opt outs. I think the paradigm they are operating under is that the young and poor will opt out. In my system they are the ones who would never opt out as they are the ones getting massive subsidies. The people that would be tempted to opt out in my system would be those doing the subsidizing — healthy higher income people. Again though it would be simple to devise disincentives for opting out while still providing the freedom.Report

      • Avatar zic says:

        I think the burden of proof is on those using the threat of coercive force in mandating insurance. Hence the reasonableness of trying to to do opt outs if practical

        So I got around to googling coercive force, and found that it means:

        (Physics / General Physics) a measure of the magnetization of a ferromagnetic material as expressed by the external magnetic field strength necessary to demagnetize it. Measured in amperes per metre Compare coercivity

        The wikipedia definition, which redirects to coercion is:

        Coercion /ko???r??n/ is the practice of forcing another party to act in an involuntary manner (whether through action or inaction) by use of intimidation or threats or some other form of pressure or force, and describes a set of various different similar types of forceful actions that violate the free will of an individual to induce a desired response. These actions can include, but are not limited to, extortion, blackmail, torture, and threats to induce favors. In law, coercion is codified as a duress crime. Such actions are used as leverage, to force the victim to act in a way contrary to their own interests. Coercion may involve the actual infliction of physical pain/injury or psychological harm in order to enhance the credibility of a threat. The threat of further harm may lead to the cooperation or obedience of the person being coerced.

        Throughout the article, there’s an element of force; some physical threat, often an illegal threat. Yet even the John Roberts Court has ruled that the mandate is legal.

        So just so that you’re clear: your use of term so casually to refer to a fine or a tax or a penalty strikes me as hyperbole. There’s no threat of imprisonment, no threat of denied medical care in a crisis, not bribes, no nothing, other then a fine, which would barely cover an annual physical with full blood work when it’s in full force; barely a month’s auto insurance for the first few years.

        So are you intentionally trying to give the impression that not buying insurance will result in coercive force, real physical threats (or demagnetizing) or are you simply trying to be dramatic for some mysterious purpose?Report

      • Avatar Michael Drew says:

        Who would opt out of a subsidized -for- the-working poor, free to the non-working program with automatic withdrawal and penalties if joining later?

        Uh, the rich and healthy off the top of my head? Yeah, most of them bought health insurance when they didn’t have to – no one’s saying this would be the bulk of people. But some considerable number would – and did.

        I suppose you could say that all the uninsured opted out under the old system – though I think there are some wage levels at which quite literally insurance was not affordable. I think it makes the most sense to say that the opt-outers were, and would mostly be, the affluent and healthy.Report

      • Avatar roger says:

        Michael and Zic,

        Sorry. I retract my statement. I was following (or not following) the threads on my phone and was arguing the value of an opt out in a universal insurance plan which actually addresses the problem, not Obamacare. My bad.

        My point to clarify is that in real comprehensive reform which provided universal catastrophe insurance with subsidies for the poor that an opt out would be essential.

        Sorry for the misdirection.Report

      • Avatar LWA says:

        @Roger- totally understood- those Obamaphones are kinda cheesy amirite?Report

  10. Avatar Vikram Bath says:

    One of the most contentious bits regarding Obamacare is the mandate.

    I think the reason that the mandate was contentious was because it was the strongest avenue for challenging the constitutionality of Obamacare, not because it is the piece that opponents found most problematic.

    If we were to do a historical analysis of the arguments used in the debate, I would bet that criticism of the mandate picked up more steam after passage and when state attorneys started suing. Prior to that, you heard other critiques about things like death panels.

    I guess what I’m saying is that if we got rid of the individual mandate, there would still be a lot of people mad about Obamacare.Report

    • Avatar Patrick says:


      Here’s the problem, one chunk of the government has gotten itself in a self-contained tizzy that really put them in a bind, there’s no out.

      When your political opponent has put themselves in a position where there’s no where to go, your choice is to let the situation burn to the ground, or invent an out.

      I thought this madness would be done already because it can’t possibly be the case that the GOP money isn’t screaming its freakin’ head off. Even a CEO of an insurance company who was all fine and dandy about the GOP standing fast on “give my industry some bonus cheddar to go on top of Obamacare” can’t be all that happy about the prospects of a sizable chunk of his or her personal wealth evaporating in 7 days. The money has to be making phone calls. For all of the popular support the gerrymandered tea partiers feel at home, politicians like having donors and the GOP has traditionally relied on people with large pots of money and corporations to provide the lion’s share of that, and I don’t see any of those people being happy about the debt ceiling.

      That is just not working. If anything, it’s ratcheting up the pressure on somebody who doesn’t see an out, which is just making them more incoherent. Instead of cracking towards backing down, we’ve got multiple Congresspersons now talking about how a debt ceiling cross wouldn’t be that bad.Report

      • Avatar Kim says:

        Au contraire.
        Kochs and the Vast Right Wing Conspiracy, and all the other right wing crazies, want a default.
        You’ve got to be fucking kidding me if you think that these Moneyed Interests can’t bet to WIN if we go into default.
        They WON when they crashed the world market with Lehman, remember?

        Chamber of Commerce is howling bloody murder, but nobody listens to them.Report

      • Avatar Patrick says:

        You’ve got to be fucking kidding me if you think that these Moneyed Interests can’t bet to WIN if we go into default.

        (snort). Yes, any one individual can short anything. Assuming they can find someone to take the other side of that wager.

        That’s a big assume, when you’re talking domain-wide crisis moments.Report

      • Avatar Burt Likko says:

        Did you see what happened to bond markets Monday? A decent number of people think the government will default next week, and are betting accordingly.Report

      • Avatar Patrick says:

        I expect that some portion of that is people laying off their existing bets.

        If all you do for a living is make bets, there will come a time when you’ve bet money on the 49ers to cover the spread at one casino, and you’ve bet another sum of money on San Diego to cover the spread at another casino.Report

      • Avatar BlaiseP says:

        Please. Kim. The grownups are talking. Have you seen the money coming out of the T-Bond market? Do you think anyone’s going to win this go-round if the world’s most important financial entity fails to pay its bills? An instant Depression would arise, one which would make the previous Great Depression look like a Sunday School picnic. It’s an ill wind which blows no good — except this wind. This will be fuggin financial asteroid strike, a Permian Extinction event.Report

      • Nob Akimoto Nob Akimoto says:

        The problem with getting rid of the mandate is that you would essentially bankrupt the insurance industry if you did that absent removing the Guaranteed Issue provision (which also just happens to be the most popular part of the bill).

        Do you wanna bet how many people will want to claim credit for throwing people with pre-existing conditions out into the cold again?Report

      • Avatar Michael Drew says:


        So is what you’re saying that this post is actually motivated by the debt ceiling standoff more than really feeling people’s displeasure about the mandate?

        If so, let me disabuse you of a misconception: the debt ceiling standoff is not happening because people are unhappy about Obamacare. The debt ceiling standoff is happening because not raising the debt ceiling is a hammer that the hard-right found in its hand, and it wouldn’t in a million years consider not using it to do some hammering. Last time it was used to hammer on the issue of the debt and spending (somewhat more appropriately); this time it at least stated off as being used to hammer over Obamacare. In both cases those are just the things that were chosen to use this extreme leverage against; in both cases it’s being used simply because it’s available – because they think they can get policy concessions out of it, because they know it puts the president in a terrible spot, and because the base would not forgive them for not doing it now that they understand the power of the blows that can be struck with this hammer. If we had already resolved their concerns over Obamacare, there would be other demands (they’ve got plenty), because this is not a fight over policy driven by concern about policy (though everyone involved does care about policy), it’s a fight over tactics driven by intoxication from the fumes of the solid-rocket-fuel power of a particular tactic that has been stumbled upon, whose use was previously governed only by an uneasy norm that a temporarily empowered minority has less than no use for.Report

      • Avatar Kim says:

        Who wins when everyone loses?
        1) People who were jack-all poor when this started. Everyone else gets pulled down to their level, and that’s good, right?
        2) People who measure their entire value by how much better than everyone else they are. You know, folks like the Kochs. If necessary, they can ride out the storm in… Uruguay was it? The one without an extradition treaty…

        Yes, most people are going to lose if there is a default. Some people will win, at least in a relative sense.

        Some people predict that they’ll win in a depression. Some proportion of them are right.Report

    • Avatar Will H. says:

      I was advocating for death panels for the elderly way before Obamacare ever became a bill.
      Just tell the codger that they’re going to the chiropractor, put a hand on the chin, and yank hard to one side, and it’s Sweet Dreams, Granny.
      Like any good government program, one size fits all.

      If there’s a way to mandate the death panels, that will take care of a lot of my objections to the mandate.Report

    • Avatar zic says:


      I recall reading the other day about the robust CDS market on US Treasury Bonds, basically a bet on default.

      People are taking both sides of that bet.Report

      • Avatar Patrick says:

        They will be surprised to find that it is not turtles all the way down.

        Or maybe they won’t, but then I’ll be surprised. I’ve come to the conclusion that there are a great number of financial wizards who can rock a balance sheet like nobody’s business who don’t understand even the rudimentary bits of monetary policy.Report

  11. Avatar NewDealer says:

    I am theoretically a Tommy Boy.

    For the past two years, I have been paying for my own insurance. I pay around 255 dollars a month and have a 2000 dollar deductible. I’ve had some medical expenses in that time frame but not even close enough to make the deductible. I was able to get reimbursed though because San Francisco mandates health savings accounts for all long-term temps (anyone working more than 3 months) and others employed in San Francisco and my employer at the time needed to put X amount into my account.

    Now I am freelancing for a company in the East Bay. There are benefits to this but one non-benefit is no longer being eligible for the health savings accounts and paying health insurance while being healthy.

    I was looking at covered CA yesterday and it looks like I will need to pay 50-150 dollars more for the same amount of coverage. So again I will have a 2000 dollar deductible. I could pay less but those plans have a 5000 dollar deductible. It seems there is a crude mechanism that involves my income (which is good but freelance so it can drop to nothing quickly) and potentially my zipcode (I can’t confirm but I heard that Covered CA carves the state into little economic zones) and I happen to have a rent controlled apartment in a good economic zone.

    Part of me feels like I am being punished by the forces of fate for being young, healthy, and also being a freelancer with a large income and unqualified for any subsidies. I wonder if my freelance income decreases whether I qualify for subsidies.Report

    • Avatar Kim says:

      Personally, I can’t see why folks like you aren’t scared spitless right now.Report

    • Avatar Kazzy says:

      “…and also being a freelancer with a large income…”

      With all due respect, calling that fate is a bit of a stretch. That is a choice.Report

      • Avatar NewDealer says:

        Not really considering the legal market. I would love an associate position. The only positions I see advertised are for people with 5-10 years experience who have taken at least one case from start to a trial.

        I’m doing very well in many respects and can’t complain but there are also large aspects of my life that are treading water that can potentially turn to drowning very quickly.Report

      • Avatar Kazzy says:

        But you chose to be a lawyer.

        Age, we can’t control. Most aspects of health, we can’t control. But our career? Our employment? We exercise a great deal of control over that. Not absolute control, but a great deal. You could have chosen a path that would have secured you better options with regards to health insurance and health care coverage. You opted not to, as is your right. That doesn’t mean you should get left out in the cold and there is something peculiar* about your situation being made far worse by the PPACA, but you were fated towards that situation.

        * Peculiar in that it seems to run counter to the purpose of the legislation as it was advertised; not peculiar as in rare or as in I think what you are saying is untrue.Report

    • Avatar LWA says:

      Well, there are worse punishments of fate than to be young, healthy, and with a decent income.Report

      • Avatar NewDealer says:

        True. There are a lot of things that I can not and should not complain about.

        But see my response above to Kazzy. Being a freelancer is like being on a precipice especially because of the government shutdown and potential default scare.Report

      • Avatar BlaiseP says:

        I’ve been an independent consultant for many decades now. Being independent, to use an old cliche, is jumping off a cliff and building an airplane on the way down.Report

    • Avatar Brandon Berg says:

      Person espousing an ideology in which people are punished for having high incomes complains about being punished for having a high income, attributes it to fate.

      In other news, chickens appear to be coming home to roost.Report

  12. Avatar Jim Heffman says:

    I still haven’t seen an explanation of why “everybody is henceforth signed up for Medicare, you pay taxes for it based on your age and last year’s income” is not a workable plan.

    Actually, I should say that I haven’t seen an explanation other than “we can’t because fucking Republicans”, which is a teenager’s grump and not an actual explanation.Report

    • Avatar Patrick says:

      Would you support this solution?Report

      • Avatar Jim Heffman says:

        Yes? Why wouldn’t I? The United States already has a single-payer healthcare system. We’ve just decided that you only get to have it if you’re old.Report

    • Avatar greginak says:

      Jim- Some D’s wanted Medicare for all and pushed hard for it. No R’s would sign on to that and there wasn’t’ enough D support. In fact dropping Medicare for all was offered to R’s to try to get some to agree to supporting HCR. If R’s had been okay with it and only one or two would vote for it, we would have likely had it. The admin kept bending over and over to try to find some accommodation to get even one or two R votes in the senate( mostly from Snowe and/or Collins). If someone would put together a serious bill to get medicare for all now liberals would love it.Report

    • Avatar Jesse Ewiak says:

      To be fair, the explanation is really, “we can’t because fucking Republicans, Joe Lieberman, Ben Nelson, Mary Landreiu, and other center-right Republicans.”Report

    • Avatar Vikram Bath says:

      I still haven’t seen an explanation of why “everybody is henceforth signed up for Medicare, you pay taxes for it based on your age and last year’s income” is not a workable plan.

      I can give you an explanation:
      I am currently covered under my wife’s policy, and I’m unsure (but pessimistic) about the quality of my coverage if I were to move to Medicare. This is likely true of a whole bunch of currently-insured people, and they would fight such a plan.Report

      • Avatar Dan Miller says:

        @vikram-bath Exactly. Any plan has to be politically viable, which means not introducing huge changes to most people’s coverage. Sucks, because the current health care system is an unholy mess, but this is a fact of life that has to be dealt with by any plan.Report

  13. Avatar Francis says:

    If you’re actually asking an honest question, the honest answer is that your proposal didn’t have the votes. There are any number of complicated ways to solve free-rider problems, but none of them could command the votes the way the very basic mandate approach could.

    A deeper answer is that Congress has a terrible history of being sympathetic to people in need — and creating perverse incentives. Student loans is an obvious one being much talked about these days. It appears that the availability of cheap money has turned universities into gold-plated playgrounds. Medicare’s long-standing coverage of kidney disease is a more obscure example. (If Congress is going to pay for certain chronic diseases, then insurers don’t have to price for them. Privatized profits and socialized costs is a bad idea.)

    What would really happen is that poor crippled debt-ridden Tommy Boy would be wheeled in front of Congress, and — BAM — Congress would pass a debt forgiveness program. So it’s understandable that the simple approach — universal mandate — got adopted.Report

    • Avatar Brandon Berg says:

      Right. The bottom line is that there are many people in this country who simply will not stand for a system in which people are held responsible for their own choices. So that doesn’t happen anymore.Report

    • Avatar Patrick says:

      If you’re actually asking an honest question, the honest answer is that your proposal didn’t have the votes.

      That was then. This is now.Report

      • Avatar Francis says:

        “This is now” Do you mean that the Republican Party is proposing to hold good-faith negotiations on Obamacare, and in return for getting something that they value highly — relief from the mandate — they’re willing to offer something in return?

        That’s great news. What’s on the table?Report

      • Avatar Patrick says:

        Francis, the Republican party doesn’t have a strategy at this point.

        They dug a hole, and climbed into it, and poured concrete on themselves, and it is hardening.

        Amusing as that is from a karmic standpoint, we need them to come out of the hole and sign off on continuing to run the country. They’re refusing to come out unless… something. They’re not sure what it is, because they’re not sure how they got in the hole in the first place.

        So, we need to be creative.Report

      • Avatar Mike Schilling says:

        They dug a hole, and climbed into it, and poured concrete on themselves, and it is hardening.

        And I’d like to help them out of the hole before it sets. Anybody got a grenade?Report

      • Avatar Troublesome Frog says:

        Amusing as that is from a karmic standpoint, we need them to come out of the hole and sign off on continuing to run the country.

        I’d like to see a solution to that impasse, but only if it’s a solution that causes future Republicans to say, “Hey, remember that time we tried to hold the country hostage to get unilateral concessions? That didn’t work out very well for us, so we should never do it again.”

        If that lesson isn’t learned, we might as well just let the shit hit the fan this time around, because the Republicans will start flinging it at the fan again the moment they get the chance.Report

      • Avatar Patrick says:

        If that lesson isn’t learned, we might as well just let the shit hit the fan this time around, because the Republicans will start flinging it at the fan again the moment they get the chance.

        I doubt that lesson will be learned.

        How long are you willing to go, Frog? Burning down the government is actually regarded as a win by a number of your negotiating partners. It will take an awful lot of negative repercussions to wake them up, some of which will last maybe decades.Report

      • Avatar Troublesome Frog says:

        How long are you willing to go, Frog? Burning down the government is actually regarded as a win by a number of your negotiating partners.

        The “lesson learned” I’m looking for is not for the Tea Party crazies to learn that they’re crazy. That’s a lost cause. The important lesson here is for the sane-ish party leaders to stop lending support to the crazies. These guys don’t think that letting the world burn is a win, so they need to stop pretending that they do and rejoin the civilized world.

        All it takes to put a stop to it is for a clean debt ceiling bill to go to the floor for a vote. There are enough sane people in the Republican party to pass it with bipartisan support. Yes, they’ll pay a political price–a much greater one than if they had quietly squelched the idea to begin with. Instead, they grabbed for the One Ring power that you get when you promise a mob of gullible crazy people things that they can’t realistically have.

        If the sane members of the party learn that we give them cookies whenever they let their kooks near the doomsday button, we might as well just declare the craziest Tea Party member Dictator for Life and be done with it. I think we should be willing to pay a very serious cost to avoid that outcome.Report

      • Avatar Kim says:

        yes, the technical term for what the House is doing with the debt ceiling is coup d’etat.
        This cannot be rewarded, in even the smallest of fashions, if we wish democracy to continue.Report

    • Avatar Vikram Bath says:

      Congress has a terrible history of being sympathetic to people in need

      Especially if they are banks.Report

  14. Avatar Kim says:

    Opting out of health care is rather easy, actually… so long as you remain conscious.
    Just get a “do not treat” order on file…Report

  15. Avatar Damon says:

    No doubt in scenario 2, when Tommy Boy is wheeled into the emergency room, his “insurance info” or lack thereof, will be noted, and he’ll be quitely placed in a room or in the hallway to quietly die, so I see no reason while the hospital will spend 500k on him and hope to get paid by the feds. He won’t get any care but maybe supportive and maybe some paid meds while he bleeds out. Just a bit more elaboration on Kim’s “do not treat” comment.Report