A Spooky Obamacare Post

It’s that time of year again. The blood, the guts, the candle-lit theramin music… the open enrollment period for Obamacare is nearly here.

Premiums are up, again, somewhat steeper. Insurers have cut back or dropped from some markets. The Republicans are painting this as the dire predictions come true. But you can contrast their alternative at abetterway.speaker.gov which should probably be called “a bettor’s way”—they are betting that you’ll take them at their word that they’ve cracked the code for making healthcare work for the country rather than the country working to afford healthcare.

Getting into the bog means facing down the swamp monsters of things like age-rating. Plainly, should older people be able to be charged 3× or 5× what younger are? In practical terms that’s likely a difference of at least $500/month or $6000/year…. Obamacare says 3×, while the GOP says five by default and let the states do whatever they want (Do I hear 50×? 100×?). Their argument is that limiting the gap raises premiums for young people.

But the whole argument is fucking stupid, on both sides. You simply cannot charge older people an arm and a leg to fix their arm and their leg. And charging young people a ton is equally batty. (Caveat: in both cases, means testing should be employed such that poor people pay little and wealthy people pay more.) In other words, the main issue is cost of healthcare, and neither the GOP’s plan nor Obamacare do enough to directly address the cost issue.

The GOP’s plan makes other major strategic errors, such as a one-time open enrollment, which damns the laggards to a future without what they term “continuous coverage protections” (the idea that a new, major health problem can’t skyrocket your premiums) and automatically higher premiums when they do sign up. They’re basically lining up a whole class of people to be taken for a ride by insurers here.


What do people want? Healthcare at an affordable price. What does Obamacare deliver? Healthcare that’s affordable to the rich and the subsidized, semi-affordable to the young, to those in some luckier states, and to those who have employer-based coverage. What does the GOP plan deliver? Basically the same, with some musical chairs on who’s getting fucked over. But basically the same.

Neither party is doing anything about the real monster in this film: cost. The lobbies (minions of the monster) for hospitals, doctors, drugs, et al. are too mighty for these extras to tackle. We’re awaiting the hero of the film to slay them, and then take the monster on for the grand finale. And we’ll still be waiting in 50 years, because our planet is fresh out of heroes.

How do you tackle costs?

  1. End fee for service. Current medical billing in the USA is based around the idea that every action taken in a hospital is profit for the hospital. Every pill, every bedpan, all of it is billable. And therefore, it all must be tracked for billing purposes (it ought be tracked for scientific reasons, but that’s a different story).
  2. Stop subsidizing the global pharmaceutical industry. The USA pays premium prices for drugs while the rest of the world pays far less. Effectively, the USA is subsidizing the rest of the world (or just giving massive profit to pharma for nothing). End that. We should pay our fair share, but not more (unless it’s formally negotiated in our treaties for other tangible benefits).
  3. Require providers and insurance companies to publish the cost to the consumer if they lived in other countries. Let people know how badly they’re getting screwed every time they go to the doctor or pay their premiums. (This might be doable in another way: by having foreigners create a searchable database of conditions/treatments that US consumers could look up and see the prices. But having it on the bill would work better.)
  4. End employer-based coverage (including in union contracts). Portability laws are a bandaid over a system that obfuscates value in employment, causes undue labor loyalty, invites corruption, and so on. Workers deserve to be paid in real money, and never in trade for economic decisions they ought to make for themselves (i.e., the decision itself has an economic value that is not represented in the value of the health care).
  5. Invest in automation and allowing non-MDs to provide more care. Both of these will probably do a lot in the future, but it will take time for them to kick in.