“Of all the forms of inequality, injustice in health care is the most shocking and inhuman.”
Is it not painfully obvious to everyone now that the Affordable Care Act (ACA) is a complicated failure of a contraption, from a healthcare and a political point of view? Answer: Yes! Even Michael Moore now admits that “Obamacare is awful.”
Indeed, I contend that:
- Obamacare is not a public program, but a government-assisted private boondoggle. Its main purpose is not to ensure public health, but to insure the profitability of private health insurance companies and the private pharmaceutical and hospital industries.
- It is the product of a now thoroughly corrupt political culture in which capital openly buys politicians, elections, and laws.
- It is failing politically at every level, and is even likely to fail in its actual socio-economic goal of perpetuating the profitability of the private health insurance industry.
- It cannot be “tweaked” into becoming a real public healthcare program, and every syllable of every argument for fine-tuning it does nothing but waste time and stand in the way of ever getting the single-payer, universal coverage, Medicare-for-all that we need.
- Unfortunately, it was Democratic Obama cheerleaders like Moore – who refused four years ago to oppose the program and insist, as they should have (and promised they would!), on a public system – who helped to create the terrible situation we now have. (And Moore still seems to think Obamacare is “a godsend” that can be tweaked into perfection. See Shamus Cooke’s wonderful takedown of Moore’s weaseling.)
As Norman Solomon put it, with their “disingenuous sales pitches four years ago, President Obama and his Democratic acolytes did a lot to create the current political mess engulfing Obamacare — exaggerating its virtues while pulling out the stops to normalize denial about its real drawbacks. That was a bad approach in 2009. It remains a bad approach today.”
The result has been a situation in which healthcare has become more thoroughly privatized, and the possibility of a single-payer Medicare-for-all system – the cheaper, more effective, already-proven and undeniably popular (favored by two-thirds of the public in 2009) solution – has become deferred even further, and made harder even to see or discuss.
To fully understand how phony the whole ACA discourse is – both that of free-market “Tea Party” fundamentalists and that of Democratic-Party/Obamican free-market neo-liberals – and why Obamacare should be understood as “a fraud on the public” (Glen Ford), and “the biggest insurance scam in history” (Kevin Zeese and Margaret Flowers), we have to look at what the real purpose of the law is, and what it is not. That’s really quite obvious if you look at the forest the legislation creates, and don’t let yourself get diverted by the deceptive and confusing debate over the prettiness of this or that tree.
Obamacare is not a healthcare program. It – and, importantly, the government through it – does not provide healthcare to anyone. Obamacare does not give a penny to healthcare providers. In fact, as an analysis posted by Paul Craig Roberts puts it: “Hundreds of billions of dollars are siphoned from Medicare to help pay the cost of Obamacare.” In order to budget for the ACA, Obama has reduced Medicare payments to doctors and hospitals, actually taking public money that is directly paid for medical services and shifting it into the pockets of private health insurance middlemen.
It is not even a health insurance program. It, and the government through it, does not provide health insurance to anyone (although it kinda, sorta, partly pays for some of it, for some people). Obamacare is a publicly-funded marketing program for private insurance companies, a program through which a compliant capitalist government functions as a super-broker that forces the public to buy, and funnels public money into, private health insurance companies, which retain complete management and control of healthcare delivery behind the scenes.
It’s a boondoggle, designed, by Obama and the health insurance lobbyists who wrote it, to prevent movement toward the only reasonable and effective alternative — some form of Medicare for all, which people are literally dying for — and to save private health insurance companies by forcing people to buy their products, which people rightfully despise. Obamacare does for the despised health insurance companies what Quantitative Easing is doing for the despised banks – concocting a way to pour public money into them to keep them afloat, and keep their CEOs’ plutocratic incomes flowing. Like $21 to $47 million for the top five. Like as much as $106 Million. Like the highest average of all industries, “77 percent higher than chief executives at financial services companies.”
That’s the money drain out of real healthcare that Obamacare sustains. Liberals who think Obamacare is some kind of some kind of “step in the right direction,” rather than a new obstacle to moving forward, are no less deluded than Tea Partiers who think it’s some kind of “socialism.”
To put it in a way that right and left might understand: Obamacare is no more a public healthcare plan than the Federal Reserve is a public bank. It’s a simulacrum of a public institution that stands in for, and in the way of, a real one. Fundamentally, Obamacare is another element – a particularly nasty one because of what it’s screwing with (healthcare) – in the three-decades-long right-wing/neo-liberal denial of the social.
For the contemporary right-wing, “society” is nothing more than the net sum of individual, private transactions. Margaret Thatcher gave the tagline for this movement, with her famous insistence that “there is no such thing as society.” Following her – and their other socio-economic mentor, Ayn – American Randian Republicans have been the loudest and most aggressive promoters of the crude “greed is good” ideology that bashes any attempt to think socially with the fist of triumphant individualism.
Right-wingers are not wrong to see the ability to think socially as the basis for “socialism,” as something which, if thought through consistently, would lead in that direction. Reactionary whiskers are fine-tuned to twitch excitedly when the tiniest molecule of such an attitude brushes by. A fine, concise definition of “communism” was given by Edgar Speer, Chairman of the Board of United States Steel, when, in 1978, he explained why it would be such a terrible idea to sell Youngstown’s abandoned steel mills to the workers: “The whole concept of community-owned facilities is the same as communism — particularly where the profit of the facility will go for the social benefit of the people. This is communism.” Well-said, comrade Edgar.
But, as Democratic liberals and less-dogmatic capitalists since FDR have understood, it is quite possible to craft policies and programs embodying incipient forms of social solidarity that will be comfortably absorbed within the capitalism system. Social Security was not, and socialized health insurance will not be, the death-knell of capitalism. These programs are threats in the sense that they both provide examples of how well things can work when democratically run “for the social benefit of the people,” and they empower ordinary people to organize for greater control of society by freeing them from constant fears of sickness and penury. But we are far away from reaching a tipping-point in the security and militancy of working people that would endanger capitalist hegemony.
These reformist social programs are also sometimes politically and economically necessary. When the leaders of the $2.6 trillion consortium of for-profit health-insurance, pharmaceutical, and hospital industries sat down with Obama, their favorite
employee candidate by far, to write the ACA, this is what they all understood. They were trying to save their capitalist industry, the source of their personal wealth, from being shut down (as it should be) by a perfect storm of popular rage and threatening economic tendencies. They, including Obama, were also following the anti-social imperative to reject the possibility of taking public responsibility for the common good, in favor of insisting on a program of dispersed, “mandated,” individual private purchases.
Presidential Candidates: Selected Industry Totals, 2008 Cycle
So, in the shadows of this right-wing hoopla, it is Democratic Party neo-liberalism from Clinton to Obama, posing as a kinder gentler alternative, that has been most effective in undermining, by co-opting, the policies and political thinking that represent effective forms of social solidarity. Democratic Party neo-liberalism has been a most effective force in turning the American and global social economy into a privatized, financialized playground for plutocracy, and in promoting austerity and immiseration for ordinary working people. Barack Obama has been a most effective agent of that effort, and Obamacare is one of the most effective and pernicious tools of that project.
Would you buy a used car from this man?
To highlight this most fundamental point, I’ll begin with this observation of Noam Chomsky on “solidarity.” As opposed to the alienating, competitive individualism that serves capitalist interests, “solidarity” is the fundament of the logic and ethic of social thought, indispensable to common action for the public good. Which is why it’s been undergoing an enforced disappearance:
Today, post offices, Social Security, and public schools all have to be dismantled because they are seen as being based on a principle that is regarded as extremely dangerous.
If you care about other people, that’s now a very dangerous idea. If you care about other people, you might try to organize to undermine power and authority. That’s not going to happen if you care only about yourself. Maybe you can become rich, but you don’t care whether other people’s kids can go to school, or can afford food to eat, or things like that. …
That’s why unions had the slogan, “solidarity,” even though they may not have lived up to it. … And it’s really important for power systems to undermine that ideologically, so huge efforts go into it. Even trying to stimulate consumerism is an effort to undermine it. Having a market society automatically carries with it an undermining of solidarity. For example, in the market system you have a choice: You can buy a Toyota or you can buy a Ford, but you can’t buy a subway because that’s not offered. Market systems don’t offer common goods; they offer private consumption. If you want a subway, you’re going to have to get together with other people and make a collective decision. Otherwise, it’s simply not an option within the market system, and as democracy is increasingly undermined, it’s less and less of an option within the public system. All of these things converge, and they’re all part of general class war.
Let’s pretend we’re in a society where people are clamoring for a decent public transportation system. They are fed up with having to buy overpriced and unreliable cars from unscrupulous dealers on onerous financial terms in order to be able to get to work every day. They are at a boil over this. Along comes a smart, mellifluous, “progressive” politician, who says, to the public and to the thousands of activists who’ve been working on this issue for decades: “I’m absolutely with you on this. We need a first class, effective public transportation system. I promise you I will not settle for anything less.” He is elected, with a mandate to solve this problem and many others like it.
Now imagine that, after months of negotiation with auto dealers and manufacturers, from which the best public transportation advocates have been excluded, he proposes the following solution: To make sure that everyone has some transportation, I am going to force everyone, under the threat of a tax penalty, to buy a car – a Ford or a Lexus or whatever, you choose – from the same network of dealers that’s been gouging you all along. But Don’t worry, he says. I’m going to make sure that every car you buy has brakes, seat belts, and turn signals. What’s more, I’m going to make sure (kinda, sorta, maybe, for some of you) that you are offered an affordable monthly payment. I’ll even help you make the payment if you’re really strapped, by giving public money to those car dealers. Now, a steering wheel, that’ll cost you a deductible. A heater? Copayment. But, for the poorest of you, we’ll cap your total yearly payment at $6000 or so, over and above your monthly payments.1
Would anybody think that this was a solution to the need for a public transportation system? Any of the public that had demanded such a system? Any of the thousands of activists who had been working for it? Would anybody – especially any one of those activists – think or say that this was a “step in the direction” of the public transportation system? One would have to be an utter fool.
Such a program would be the opposite of a public transportation system. It would clearly be designed not to satisfy the public’s needs for a transportation system, but to strengthen and perpetuate the same system of selling cars, and further enrich car dealers. And this would be the case even if the politician were opposed by right-wing groups who objected to “the government” forcing dealers to include brakes and turn signals in their cars, and called that “socialism.” No serious public transportation advocate would take those right-wing complaints to mean that the program really was a public transportation system, or even a “step toward” one.
Try repeating the analogy: Public water supply? We’ll help you buy bottles of Dasani and Poland Spring. You can repeat it, because this is exactly the sort of government-assisted privatization that is the order of the day, around the world. This kind of thing has nothing to do with, is the opposite of, a public program, structured for the public interest, let alone “socialism.”
This is what Obamacare is. Once you see that – and really, how could you not? – you see that it is, indeed, fundamentally “awful.”
If you’re tempted to say: “But isn’t it better that cars have seat belts?” you are missing the point, and demonstrating the hold that capitalist, individualist ideology has on our minds, and how it diverts us from thinking socially. The private car market can be better or worse, well- or ill-regulated, with lousy products or quality ones, but none of those differences will make it a public transportation system, or a “step in the direction” of one. It does not have the same purpose.
Consider this, for example: In order to keep the for-profit private health insurers in the game, Obama has to make the pitch that healthy young people should consider it their civic duty to be forced to give money to a private health insurance company, since that company has agreed to things like not excluding pre-existing conditions. Really? It’s your civic duty to make car payments to a private auto dealer even when you don’t need the car, so that the dealer can maintain his profitability? No, it is not. This is nothing like the civic duty one would have to pay taxes into a social fund that pays directly for your and everyone else’s
public transportation healthcare. Nothing like it. Not to understand that distinction is to be trapped in a straitjacket of anti-social capitalist ideology.
It’s not that there are no good features of Obamacare; it’s that the positive features, like not excluding pre-existing conditions (but there are loopholes for that2) are “loss leaders” to get you into the showroom, buy a nice upgrade package, and sign on the dotted line for those easy monthly payments. They are all hedged in by a framework whose primary purpose is profitability. The private for-profit health insurance industry remains in charge, and it will chip away and undermine, or (same thing) try to monetize, any of the positive discrete features that were used to lure progressives into defending one more crappy piece of right-wing socio-economic policy.
In a for-profit health insurance system, “a company that sells insurance, no matter what for, does it for one reason and one reason only- to make money.” The insurance company becomes “a third party that needs to extract profit from the relationship between a doctor and his or her patient.” For-profit health insurers, who require profitability, and continual growth in profitability, are impelled to put up barriers to providing actual healthcare: “On top of the expensive monthly premiums, there are co-pays and deductibles that are huge barriers to getting treatments. We have in-network providers, out-of-network providers, and a book full of policies and percentages that gets changed every year.” (Graeme Anfinson “The Democratic Enemies of Medicare for All”)
Since it is premised on perpetuating the private, for-profit, health insurance system, Obamacare “further entrenches this mess into our lives.” Obamacare will not provide healthcare, or even health insurance to every American, and its purpose is not that. Its purpose is to ensure ongoing sufficient profitability for the health insurance industry that fashioned and controls it:
The ACA was not selflessly designed with the intent of providing affordable and equitable medical services to those in need, but rather to acquire taxpayer money for the private insurance companies under the seemingly helpful guise of health care and the ideological excuse of personal responsibility. It takes money from ordinary people and gives it to a medical insurance industry that profits handsomely from this legally-enforced corporate welfare – all while keeping Americans locked in the same broken system that puts profit before patients. The law was essentially written by business executives from the industry so that special interests would not be upset and profits assured. [Anfinson again. My emphasis]
The Swedish Way
Really, “assuring profits” is Obamacare’s purpose. Don’t take my word for it. Read the New York Times story, wonderfully titled “The President Wants You to Get Rich on Obamacare.” It’s about a business seminar at the “21” Club, given by Tom Scully of “the Potomac Research Group, a Beltway firm that advises large investors on government policy (tag line: “Washington to Wall Street”). Tom schooled his colleagues about how Obamacare is “actually more, not less, capitalistic than anything that came before.” He detailed how it will provide, and was designed to provide (“It’s exactly the kind of competition that Elizabeth Fowler, and the Baucus team, intended the law to encourage.”), myriad opportunities for new parasites to make money off your sickness:
When Scully finally began his speech, he noted that the prevailing narrative among Republicans — assuming that many in the room were, like him, Republican — was incorrect. ‘It’s not a government takeover of medicine,’ he told the crowd. ‘It’s the privatization of health care.’ In fact, Obamacare, he said, was largely based on past Republican initiatives. ‘If you took George H. W. Bush’s health plan and removed the label, you’d think it was Obamacare.’ [Yup. See also: “Why Obamacare is a Conservative’s Dream”)
Scully then segued to his main point, one he has been making in similarly handsome dining rooms across the country: No matter what investors thought about Obamacare politically — and surely many there did not think much of it — the law was going to make some people very rich. [emphasis in original]
Or take a look at “Despite Glitches, Obamacare Profit Windfall To Insurers Well Underway,” from Forbes, citing “Health plan CEOs like Wellpoint’s Joe Swedish,” who – taking in a $1.25 million salary, plus possible $3.75 million bonus, plus $8 million stock options, plus $3.56 million “compensation” for leaving his last job (Must have been a hell of a job!) – knows from windfalls:
While politicians and pundits alike inside the beltway beat up the White House over computer system glitches, health insurance companies still project robust revenue growth and profits from a boom in business from newly insured Americans under the Affordable Care Act.
While Republican Tea Partiers delude themselves that it’s “socialism,” and Democratic liberals delude themselves that it’s some kind of real humanitarian initiative for the public good, shrewd businessmen and the business press know exactly what Obamacare is about: a profit windfall.
[You thought I was going to talk about healthcare in Sweden? OK, I will. I have family living in Sweden. The adults cannot pay more than $500 a year each for healthcare -- for everything: doctors, tests, surgeries. (Not, alas, dental.) For the kids (up to 18), it's all free (including dental, not including eyewear). They have pretty good doctors, too, last I heard. Tell me about what a hard sell that would be. And Sweden is not a socialist country, although it is a social democracy.]
I cannot insist enough on the demonstrated falsity of the argument that defending Obamacare was then (or is now) the only politically “realistic” strategy.
First of all, particularly in early 2009, in the midst of a severe crisis of capitalist legitimacy, it was not politically impossible to make the case for Medicare-for-all. I chose this image
of Newsweek’s February 2009 cover as my blog avatar precisely to indicate the radical ideological and political possibilities that had opened as a result of the near-collapse of the American capitalist economy. These were the possibilities that candidate Obama so craftily surfed on to his election in 2008, and that gave Democrats control of both houses of Congress. In that context, there was absolutely no reason to presume that it would be politically more difficult to make the case for an expanded version of the enormously popular Medicare program than for some complicated scheme to force people to buy private health insurance.
Obama did not refuse to make that case because he could not, but because he would not. He did not want to, because — despite the other impressions he loves to give gullible progressives – he is a free-market neo-liberal by conviction, and favors the private healthcare system. He wanted the deal that would save and strengthen private insurance companies, not the public social fund. When he said otherwise, he was lyi…, er, triangulating. Not telling the truth.
The details of how Obama locked himself up with insurance, hospital, and pharmaceutical lobbyists to write the ACA, and ordered Democratic legislators to drop any “public option” are well known, and were well known at the time – although they were at the time, and still are, ignored by delusional Democratic constituents who want to believe that their party leaders only produce such monstrous policies because they’re hogtied by Republicans.
Back in 2010, Glenn Greenwald pointed out that: “[T]here was already ample evidence that the White House had, in fact, secretly negotiated away the public option early on in the process, including confirmation from a New York Times reporter of the existence of such a deal, as well the fact that Russ Feingold said as clearly as he could that the reason there was no public option in the final bill was because the White House never pushed for it, because the final bill — without the public option — was the “legislation that the president wanted in the first place.” The White house “secretly bargained away the public option with corporate interests early in the negotiation process,” and then “spent months after that assuring their supporters that they were doing everything they could do have a public option in the bill.” In another piece, Greenwald wrote that the Democratic Party leadership: “pretended in public to ‘demand’ that the public option be included via reconciliation with a letter that many of them signed (and thus placate their base: see, we really are for it!), while conspiring in private with the White House (which expressed ‘sharp resistance’ to the public option) to make sure it wouldn’t really happen.” (See also Miles Mogulescu at Huffington Post, and David Dayen at Firedoglake, and a David D. Kirkpatrick in the NYT.)
Hogtied? Hogwash. The Republicans did not stop the Democrats from doing anything. The Democratic politicians did exactly what they wanted (and what their constituents did not want). The ACA passed with no Republican votes. Didn’t need ‘em. Another world of healthcare was possible. People were clamoring for it. America had voted for, and expected it. It was Democratic Party health industry stooges, with Max Baucus and Barack Obama in the lead, who stood in the way, insisting that nothing else was possible. The progressive constituency, and the people of America, were betrayed by Obama and conservative Democratic legislators, who never wanted any public plan, and by compliant progressive Democratic legislators who reneged on their sworn and signed promise not to vote for exactly the kind of capitulation to the insurance companies the ACA is. Prominent liberal groups and personalities – MoveOn, the unions, and the Michael Moores – collaborated in this betrayal en masse.
It was the progressive constituency, not the Republicans, that was being fought and played by the Obama and the Democratic Party, and it was Obama and the Democratic Party who should have been the targets of progressives’ relentless pressure for a single-payer system. Bruce A. Dixon of Black Agenda Report nailed it back in 2010:
The real health care fight waged by the Obama administration has not been against Republicans, who never had the votes to stop, let alone dictate or pass anything. The administration’s effort all along has been to pass the worst bill possible, with the greatest amounts of corporate welfare and loopholes, and the fewest protections for patients, while silencing, neutering and coercing the voices of most Democrats, who have favored some form of single payer, or Medicare For All from the beginning.
There is no good feature of Obamacare that could not be handled better in a public, single-payer system. It is not as if the American private health insurance market functions in a way that satisfies anybody but the insurance companies. People were at a boil about it. It is absolutely not the case that there is no better public alternative. We have one that’s been working for going on 50 years. All we have to do is let everyone in it. This is not a hard argument to make, for those who might actually want to make it.
Not only was it politically possible to make the case for single-payer Medicare-for-all, it would have been more politically/electorally advantageous to do so. If they had made the case forcefully for such a clear and simple solution, Obama and the supposedly progressive Democrats would have put the Republicans in the rhetorical position of arguing against Medicare. Even if, because of resistance by reactionary Democrats, they had failed to pass the legislation at first try, they would have laid the ideological and political groundwork for continuing the debate, and strengthening their electoral position. That is serious politics.3
Instead, unable to generate any logic or passion for a complicated program involving forced purchases, new taxes, and hidden confusions – which, to this day, no one understands – Obama and the Democrats gave the Republicans a chance to pose as defenders of free choice and Medicare, and to re-constitute a newly aggressive, revanchist, laissez-faire ideology. In the context, it was an enormous defeat, with horrible long-, or at least mid-term consequences for the Democrats electorally, and for the country ideologically. As Norman Solomon says:
Obamacare’s little helpers, dutifully reciting White House talking points in 2009 and early 2010, were helping right-wing bogus populism to gather steam. Claiming that the Obama presidency would sink without signing into law its “landmark” healthcare bill, many a progressive worked to throw the president a rope; while ostensibly attached to a political life preserver, the rope was actually fastened to a huge deadweight anvil.
The Democrats avoided fighting for single-payer Medicare-for-all, not because of electoral opportunism, or even stupidity, but because, in principle, it is not what they wanted, or want, to do. They left the politico-ideological initiative to reactionary Republicanism because the Democratic Party, as an institution, prefers a politico-ideological field where laissez-faire capitalist ideology aggressively dominates to one where a more cooperative social ideology militantly challenges. They neither want, nor know what to do with, the latter. Until progressives understand this, they will continue to be the victims of the same scam without end.
As Shamus Cooke points out, for four years since the ACA was passed, the whole Democratic Party, and
liberal and labor groups … frittered away their group’s resources—and integrity— to sell a crappy product to the American people.….adding crucial political support to a project that deserved none.
…Obamacare was always more barrier than progress: we’ve wasted the last several years planning, debating, and reconstructing the national health care system, all the while going in the wrong direction — into the pockets of the insurance mega corporations.
A true public and progressive system will not be an adjustment to, but a total replacement of, Obamacare. Obamacare is failing politically, and may very well fail in other ways, as analyzed below, and that is an opportunity. The task for progressives is not to conjure new means of life support for this political zombie, but to put it out of its misery. It has to be replaced by a vibrant social program, a public, single-payer system in which the criteria of success is not profitability, but universal coverage and the health of all our citizens – because that’s what we as a society think is the right thing to do.
This means unapologetically putting an end to a mulit-trillion-dollar business that is the source of millions in campaign contributions, that is the income stream for the lifestyle of scores of plutocrats who are also politicians’ friends, and that is a destination sinecure for many politicians themselves.
This is also a demand to reverse the tide of austerity, and expanding and strengthening social programs, instead of destroying them, may also require a complete reform of tax policy. Programs like Medicare and Social Security should be funded from the general tax revenue, with a simplified and truly progressive tax code that eliminates loopholes and treats capital gains the same as wages.
Sure, this will require a militant political movement based on an ethic of social solidarity, as opposed to private enrichment, that both major political parties have effectively abandoned. That’s what’s needed to address all the problems we face. It’s that, or waste another four years defending Obama, and chatting up the next Democratic shill.
Lost in the Woods
The debacle with the website was a canary in the mine. It was a secondary, but not insignificant problem. It was significant in itself, because it was, in its own right, a failure of the Obama administration, which had four years to prepare something that actually worked. But it also indicates how a liberal concession to a complicated, semi-hidden complicity with private capital ended up in a failure that feeds capitalist ideology itself.
Let’s see: First, the administration outsourced the programming to a Canadian company that had been fired by the Ontario government for missing three years of deadlines. Then, it’s clear that Administration officials did not understand the difference between a “webpage” and a complex programming and database architecture. It’s also clear that they thought that adopting the pose of some hard-nosed politician from House of Cards and ordering that everything must be done on time was the way to get that complex programming architecture built. It’s clear that the contractor yes-manned and yes-ma’ammed its way to the bank. It’s clear that both the Administration and the contractor ignored warnings, lied to Congress, and generally thought they could cover up any flaws on the fly. It’s a classic tale of incompetence and arrogance over four years, for which nobody but the Obama administration is responsible, and for which nobody has been fired.
It is secondary, most obviously because it will be fixed. They’ll get enough competent programmers to make it work. But it’s also secondary in the sense that the complexities of the programming task are a secondary effect of the complexity of trying to digitally coordinate hundreds of independent systems of for-profit companies and government agencies, even though it’s “the government” that will get all the blame for it. As Zeese and Flowers point out “in 1965 when Medicare started, everyone 65 and over was enrolled within six months – using index cards.” By “the government.” It wouldn’t have been a hundredth as difficult to add everyone to the Medicare rolls.
I had my own experience that indicates the layers of public-private complexity. I helped someone who had to sign up for a new Empire health insurance plan by January 1st. We could not get signed up, even provisionally, until December 11th, and could not actually pay the premium (which is the real confirmation of coverage) until December 31st, after three hours on the phone. She still does not have a new ID card or any plan documentation, and she is still not sure she is covered for the same doctors and hospitals as before, which are indispensable for her ongoing condition (though it’s likely she is).
This was not an Obamacare website problem. This was a current Empire policyholder trying to get an off-exchange plan directly from Empire, at their website, and through their phone centers, using her existing account. Empire Blue Cross, which is also Anthem, which also seems to be Wellpoint, which had personnel in Virginia and New York trying to figure out a New York plan, was pretty clueless. Yes, they had a zillion new customers (poor them), and, yes, they also had four years to prepare.
So, although our current ideological discourse will place the blame in this way, these problems are not the fault of “the government” per se. There is no “government” in the abstract. The more precise way to put it is that this is not the fault of a government truly acting as a representative of the people, in the public interest, for the common good. It definitely is the fault of a government that makes itself the coordinating salesman of a consortium of private profit-making enterprises, a government acting in the interests of perpetuating their profitability. That’s the government we have.
One has to appreciate the perfection of the ideology: by implicating itself in ensuring the profitability of private sector enterprises, this government actually feeds the discourse that “government” in general, understood as any form of common social action outside the sphere of profitability, is to blame. This is now a well-implanted ideology. You cannot defeat it by sidestepping it.
If you’re looking for the fish at the poker table, you’re it. The liberal constituency – Michael Moore personifies it – goes along with an awful program like Obamacare, which it knows cedes too much (the essential substance!) to the right, because the liberal constituency thinks it’s an effort by “their” shrewd leader and Party to defeat reactionary ideology by evading it. What’s actually happening – you’d think they might notice this, when they’re losing hand after hand, while reactionary ideology keeps winning all the chips — is just the opposite: the party being played, evaded, and defeated is the liberal constituency itself.
I’ve previously characterized the Democratic Party strategy as “If we lose, we capitulate because we must; if we win, we capitulate because it’s the right, bipartisan, thing to do.”
Liberals who support what they know to be “awful” Obamacare, because it’s always necessary to cede to the discourse of the right, shouldn’t be surprised when the only “tweaks” to the program we’re now likely to see are those from the right itself.
And whaddaya know, they have already begun. Here’s the story of what happened to the the public subsidies to private health insurance companies through Medicare Part D. These are subsidies from which “U.S. drug manufacturers are reaping a windfall from taxpayers because Medicare’s privately administered prescription drug benefit program pays more than other government programs for the same medicines.” These subsidies were gifts to private insurers that Bush introduced as a way of getting private insurers’ noses into the Medicare tent at the public’s expense. Obama promised to cut them to help pay for the ACA. You know, the way he actually did cut direct Medicare payments to healthcare providers:
“In a reversal that followed intense lobbying from the health insurance industry,” the CMS “said on Monday it will increase the rate by 3.3 percent in 2014, reversing a 2.3 percent cut announced in February.” The many “free market” fans of increasing this Republican federal subsidy to big businesses were applauding. At fool.com, Sean Williams bannered “The Insurance Industry Shows Obamacare Who’s Boss,” and exulted “The insurance industry effectively dictated itself a raise.”
Robert C. Townsend, a successful business executive and management guru who ran Avis in the 70s, is reputed to have said:
America is run largely by and for about five thousand people who are actively supported by 50,000 beavers eager to take their places. I arrive at the round figure in this way: maybe 2500 megacorporation executives, 500 politicians, lobbyists and Congressional committee chairmen, 500 investment bankers, 500 commercial bankers, 500 partners in major accounting firms, 500 labor brokers. If you don’t like my figures, make up your own. We won’t be far apart in the context of a country with 210 million people. The five thousand appoint their own successors and are responsible to nobody. They treat the nation as an exclusive whorehouse designed for their comfort and kicks. The President of these United States, in their private view, is head towel boy.
Adjust for the new, generous, tipping etiquette, which gives towel boys and pool girls a path to junior membership. Adjust for the resulting political system that “is not only run by plutocrats, it’s become a system for making plutocrats,” with, for the first time, more than half of our legislators now millionaires – as I’ve said previously, “a government of millionaires hired by billionaires.” Adjust the ratio of investment bankers, in an aggressively financialized economy. Adjust any way you want: In a population of 316 million people, it’s a tiny group that controls the country, and it’s capital who’s the boss.
(Mark Leibovich chronicles how thoroughly this culture of corruption saturates our polity in his book, This Town. For a good précis, take a look at his appearance on Bill Moyers.)
As with the national electoral process, behind the distracting public facade, the national legislative process is almost (?) completely controlled by this corrupt coterie of Serious People, and Obamacare was their production.
The specifics of how Obamacare will work need some attention, because they help to indicate the extent to which this plan is designed for private profit as opposed to public good. Devilish details, and all. But it is ludicrous, a fool’s game, falling into the trap, to try and tote up how many people will do better vs how many people will do worse. That is precisely the anti-social exercise of calculating the net sum of private transactions.
Frankly, I suspect that most people who think Obamacare is some kind of “progressive” achievement just do not know much about it beyond the PR slogans on MSNBC. How could anybody know much about it? It is incredibly complicated. No, really, incredibly complicated. The very best single document I have read, which delves into all the details of this program, was published by Paul Craig Roberts, and can be found here. I know that I did not understand what the ACA actually was, did not know what I was talking about, until I read that piece. Take a look at it – it’s very detailed, you may not go through all of it, but pick a section – and the slogans will disappear. You will never again be fooled into thinking that this is anything but a scam to force-feed profits to the private health-insurance industry.
We know that a lot of people who could not buy health insurance will now be able to – though at complicated rates, and with varying levels of actual healthcare. We know that some people who had health insurance will now pay more, some less. Some will get better policies, some worse. And we don’t need to know much more than that. These inconsistencies are themselves a sufficient indictment of the whole awful concoction, because they derive from no healthcare logic, but only from the profit demands of particular companies. It’s ridiculous that an American citizen who lives in county x should have different healthcare coverage than one who lives in county y. Period. No tweaking.
But there’s more: Everyone is now aware that Obamacare will leave millions of people without health insurance (But did you know that figure is 26-27 million in 2016, according to the Congressional Budget Office?), and millions of others with health insurance they cannot afford to use. We also know, since it keeps all the insurance companies in the game, that it’s not going to reduce the paperwork for doctors, and it’s not going to stop the kind of insulting demand on their time, and total diversion from real medical care we see in stories like this: Doctor’s Office Spends 2 Hours On Hold With Health Insurer For Patient’s Surgery Authorization. We know, too, that the insurance companies are going to limit the doctors and hospitals they cover, especially in the cheaper plans (Insurers Push Plans That Limit Health Choices), and we’re rightly afraid that doctors themselves are going to hate it and opt out of it. Did you also know that the ACA will actually force people into and out of Medicaid without their consent? That it will force doctors to use HMO-type “productivity” criteria that will incentivize them to avoid sick patients and rush through all the others as cheaply as possible?
The ACA is a stew of ludicrous contradictions, exceptions, and regulations that are unrelated to any real healthcare needs, and only made necessary by the profit imperative underlying the whole mess.
Go for the shirts
Let’s take a look at this from another angle: the likelihood that the insurance companies will get what they want from Obamacarre. This requires a little case study.
We’ll use my locale, New York City. New York state and city had a number of insurers (good “competition”), a lot of good regulations, and very high rates. An individual policy cost nearly $24,000 a year. That is not a typo. Here’s the letter with the last rate increase for a couple (and it was not the most expensive policy available, and it was the same for all ages):
The rate for what seems to be a comparable policy now will be about 60% cheaper.
[Disclosure: I went on Medicare in 2013, so I’m out of that onerous burden. But this savings is a great personal and family benefit. There are going to be very few people in the United States who save more from Obamacare than those close to me. That’s not the point, though, is it? It’s not working out as well for these folks in Summit County, Colorado, or these employees of a car dealership [couldn’t resist] in Michigan. The way to judge an ostensible public health plan is not by this or that private cost, or the net sum of private costs, but by the social benefit it actually provides. Healthcare has to become a social right, not an individual purchase.]
We should carefully remark, in the Empire letter above, the phrase: “Rates have been approved by the New York State Department of Financial Services.” This was, as I said, a regulated market, and the DFS was supposedly looking out for consumer interests. Fifteen years ago, the individual rate was around $500. It increased inexorably, year after year. The regulators were driven by the insurance companies, who really made the decisions. Obamacare “oversight” will be no more rigorous, managed by the insurance companies, with, again, a mandate to maintain their profitability.
This means that premiums (not, by far, the full cost of the insurance) will continually go up. How fast and far they rise will depend on whether Empire gets enough healthy young people, who certainly were not buying at the above rates, to buy into their cheaper plans. Empire will have to get enough healthy new customers who won’t be making much use of their product, to make up for what’s about $1200 a month they are losing on their legacy higher-paying customers. This is the kind of bet that hundreds of companies across the country are making, and it’s no sure thing. The point of this program is to allow the private health insurance companies to make more profits. If they don’t, it fails, in its own real capitalistic (as opposed to its ostensible humanitarian) terms.
Let’s take an example:
Say you’re a 40-year-old, non-smoking single adult living in Brooklyn, and make $46,000/yr (for simplicity, above the cut-off for subsidy, but definitely not living large). You’re paying at least $15K a year for rent (a share at this price), utilities, metrocards, basic cell phone (no cable or netflix) – whatever you need to get to work, before you buy a loaf of bread or a shirt. You gotta have some food and shirts. Let’s say another $2400/yr for other necessities. This is New York: these are very conservative figures. You’re paying about $3200 in income and payroll taxes. You’re down to $25,400/yr ($2116/mo) for everything else. You’ve got a clean shirt for work, but still not one movie ticket or beer for yourself. No diapers for the kids. No visits to the parents. You’re perfectly healthy. You have this choice:
- You buy the cheapest Empire Bronze plan. You pay $4320 ($360/mo) in premiums plus $5800 in deductibles before the plan starts paying benefits, with a $6350 out-of-pocket maximum if you actually use the plan.
- You don’t buy insurance, save that $4320, and pay a tax penalty. In 2014 that would be a maximum of $460 (1% of MAGI), rising in 2014 to a maximum of $1150 (2.5% of AGI). (The penalty will actually be less than these figures, since I calculatesd assuming the gross salary equals Modified Adjusted Gross Income, when MAGI is actually always less. Don’t ask about that “Modified.” Incredibly complicated.)
Any way you look at it, you save over three grand by not buying the insurance. That’s real shirts, beers, and diapers. And, guess what? You can always go and buy the insurance if you get sick. And guess what else? According to the law: “taxpayers shall not be subject to any criminal prosecution or penalty, tax liens, seizure of bank accounts or garnishment of wages for failure to pay [the penalty] and no accumulation of interest on the unpaid balance.” Yes, the IRS will deduct the penalty from any tax refund that you get it, but no penalty of any kind, they can’t bug you for it, and you’re still $3K in the black. So what’s the downside for you in forgoing the insurance?
Now there may be some people who will remember that the President, that nice man they voted for, who struggled mightily against those Republican ogres to give us all the gift of Obamacare, says that it’s their civic duty to pay that extra $3000 per year to make sure Joe Swedish is well-enough compensated for leaving his last eight-figure job.
There may even be a few who, starting down that path of thought, remember the argument that “polemicist” guy made about what is and isn’t civic duty, which suddenly seems worth considering.
But there are certainly going to be a lot of healthy young people – I’m guessing millions – who are just going to do the math and go for the shirts. Why the hell not?
In other words, millions of people will remain uninsured, and end up paying more taxes for that honor.
Wasn’t it sooo much shrewder politically to fight for this than Medicare-for-all?
This is, first of all, absolutely ridiculous. Should people not be pissed off about this? Why shouldn’t any extra tax you pay end up buying actual health insurance? Because the minute you ask that question, and think about it for more than three seconds, you end up with some form of Medicare-for-all, paid for by a progressively-structured tax, as the only sensible answer.
But this also means trouble for Empire, and Joe Swedish, and the whole contraption. A Reuters article emphasizes the concerns that “the market won’t attract enough young people to keep it financially viable, putting more pressure on government funds to compensate for any insurer losses.” So far, according to preliminary and incomplete data, 22% of 18-34 year-olds have en enrolled, as opposed to the 38% the administration hopes for in 2014. As one “actuarial consultant” emphasized: “The whole insurance relationship is counting on them signing up….Otherwise rates will have to increase.” And as another academic noted: “If the demographics come in poorly, insurers are going to lose money.”
Which is why we have made-for-mockery amusements like the “brosurance” appeal that Jon Stewart and Aasif Mandvi lampoon so well. The reluctance of healthy young people, combined with one of the best provisions of Obamacare – the requirement that health insurance companies spend 80% of the consumers’ premium dollars they collect on actual medical care rather than overhead and profit – is going to make it harder for health insurance companies to get the kind of profitability they think they need.
Watch for more Democratic and Republican “tweaks” to fix the profitability problem! But, if they try to “save Obamacare” by waiving that 80% requirement and/or stiffening the tax penalties and their enforcement, there will be more political hell to pay, and they know it.
This all means that, as we are seeing Obamacare failing politically, there is a very good chance that it will fail in its actual socio-economic goal of maintaining the profitability of the private health insurance industry – in other words, failing the capitalist interests it intends, as much as the people it pretends, to serve.
Here, from Christopher Petrella, is another little thing about the penalty tax for progressive defenders of Obamacare to look at.
Unfortunately, the penalty-tax that the individual mandate imposes will soon constitute one of the most regressive taxes in the United States. … [It] inherently disadvantages low income earners who, in effect, pay proportionally more on fewer dollars. Taxes imposed here are uncannily akin to the regression rates of sales and social security taxes. Take a look at the scatter chart below:
Regarding the famous premium subsidy — officially the “premium assistance tax credit” – we should be aware that millions of people are going to owe premium subsidy money back to the government. Any premium subsidy the government pays to the for-profit health insurance company on the taxpayer’s behalf is only a provisional tax credit, subject to being re-billed to the taxpayer if his or her actual income exceeds the estimate on which the subsidy was calculated. The “premium assistance tax credit” is not a gift to the taxpayer, but to the insurance companies.
Other subsidies, to reduce the burden of deductibles, co-insurance, etc., are only available to those with incomes between 100% and 250% of the federal poverty level, and only if they buy a Silver plan (higher premiums, more public money to the insurance companies).
There’s a pernicious, and I think deliberate, side-effect to this subsidy policy. The jumble of regulations, penalties, and subsidies is another contraption for reproducing class, really intra-class, resentment and division. People like my Brooklyn exemplar, whose income is a bit too high for any kind of subsidy, will probably have to choose the plan with the lowest premium, and will also have to pay for every penny of deductible and co-insurance out of his her own pocket. S/he is going to see some folks with less income getting bumped into better plans because, in a given venue (Different everywhere!), a family that qualifies for all the subsidies may be find it cheaper to opt for a Silver plan with a nominally higher premium. Brooklyn Jack or Jill may not feel so great about that. This is the kind of intra-class resentment that these kinds of means-tested, particularized purchase plans (as opposed to a simple universal-coverage plan) foment – and it is exactly what they are intended to foment.
The idea is to get Camden Mary and Brooklyn Jill, two people whose incomes are an inch apart – and not in the same galaxy as Joe Swedish – fighting over who gets one dime more from “the government.” The idea is to keep them clueless about the fact that it’s Joe Swedish who is getting all the money from the government, and to prevent them from ever thinking about how everyone can get healthcare coverage that’s equally good, if we’d just leave Joe out in the cold.
The Humane Physician
Bottom line: Obamacare is a system that’s fundamentally irrational and unjust. It’s a system that won’t work well for anybody it pretends to serve, and will perpetuate enormous social inequalities in the access to healthcare.
The sole focus of healthcare progressives now must be to promote a true single-payer, universal coverage, Medicare-for-all system, which means – There’s no avoiding it! – quickly and thoroughly ending Obamacare, along with the parasitical $2.6 trillion profit machine that produced it, and that it sustains.
It’s a common mistake to think that Karl Marx conceived of the term “cash nexus” to describe the alienating structure of relations in capitalist society. He and Friedrich Engels certainly did appreciate the point, and expand on it, but it was the nineteenth-century British conservative writer, Thomas Carlyle, in his tract, “Past and Present,” who first insisted that “Cash payment is not the sole nexus of man with man.” He was railing against the ethic of “Supply-and-demand, Laissez-faire and such like” that was associated for him with the “liberal”4 faction of the day. In the same text, he recounted the following story, which, like MLK’s quote above, still strikes the heart of the matter – the utter folly of a privatized, capitalist market approach to something (the health of the people!) that is an unavoidably social problem:
A poor Irish Widow, her husband having died in one of the Lanes of Edinburgh, went forth with her three children, bare of all resource, to solicit help from the Charitable Establishments of that City…referred from one to the other, helped by none;”You are no sister of ours; what shadow of proof is there? Here are our parchments, our padlocks, proving indisputably our money-safes to be ours, and you to have no business with them. Depart! It is impossible!”
—till she had exhausted them all; till her strength and heart failed her: she sank down in typhus-fever; died, and infected her Lane with fever, so that ‘seventeen other persons’ died of fever there in consequence. The humane Physician asks thereupon, as with a heart too full for speaking, Would it not have been economy to help this poor Widow? She took typhus-fever, and killed seventeen of you … she proves her sisterhood; her typhus-fever kills them: they actually were her brothers, though denying it! Had human creature ever to go lower for a proof?[Slightly rearranged. Carlyle’s emphasis.]
Let’s not go any lower.
The last word to Glen Ford of Black Agenda Report:
The fatal flaw in Obamacare can’t be fixed. The best thing that could happen would be a quick and total collapse. Large majorities of Americans still support Medicare for All, but Obamacare stands in the way of a real national health plan – just as the Republican right-wingers that invented Obamacare back in 1989 intended.
Notes and Links
1The cheapest New York State individual “Bronze” plan has a $360/mo premium, a $5800 deductible, a 50% coinsurance after that deductible, and a $6350 out-of-pocket limit. Double the deductible and coinsurance for families. (Empireblue.com)
But a loophole in the law allows insurers to rescind (cancel) your policy if you intentionally put false or incomplete information on your application. The ACA says you must be given at least 30 days’ notice before your coverage can be rescinded, giving you time to appeal the decision or find new coverage. So, if your care becomes costly for the insurer and you didn’t mention you had a rash on your arm when you were 15, that’ll work. How can you prove if leaving this out was intentional or not? It’s them against you.
One of the great selling points of the ACA con is that those with pre-existing illnesses will not be denied coverage. This is true, but insurers have many ways to avoid the ill. …
One way to avoid the sick was mentioned above: excluding hospitals where people with serious health problems go, like major medical centers. Another way is by providing poor service to people who have a lot of claims so they change insurers. And a third has to do with the fact that insurance companies are allowed to charge more in geographical areas where health costs are higher. If a plan in a particular area is not making enough profit, the insurance company can simply stop selling in that area.
Insurance companies also can charge three times as much based on age. Because most pre-existing illness comes with age, this greatly undermines the protection of those with pre-existing illness. Insurance companies are excellent at gaming laws and regulations, so we can expect more creative avoidance of people who actually need health care.
3Consider even what might have been a “compromise” proposal: Would it have been “impossible” to get an extension of Medicare to cover everyone older than 54 and younger than 25, with others having the possibility of buying into Medicare? That would have been a real step in the right direction, because it would have preserved, strengthened, and extended the public social fund that serves the common good. It would also have grabbed all the boomers, all the students, and every parent, and brought a lot of new money into Medicare. Can anybody seriously think this would have been a harder sell, than the incomprehensible hodgepodge of the ACA?
A well-connected Democratic source swore to me that the Democratic congressional leadership, working with Howard Dean, was ready to introduce some kind of Medicare expansion like that, but was ordered by the White House to drop it, which they dutifully did.
4Thus our use of the term “neo-liberalism.” And therein lies another long story about the convoluted trajectory of political words.
October 30, 2013.