Archives For Obamacare

The View From Your Obamacare

Andrew Sullivan —  Jan 1 2015 @ 2:31pm

Some final remaining emails for one of 2014’s best reader threads:

Before Obamacare, I had individual health insurance (I’m a freelance writer) that cost $375 per month and had a $6000 deductible. I also have a bum shoulder, and my physical President Obama Visits Boston To Talk About Health Caretherapist stopped accepting my insurance, so I had to pay him out of pocket. In other words, my expensive insurance was pretty worthless.

When I looked into changing insurance a few years ago, the rates quoted were more than double due to my “pre-existing” condition of a bum shoulder coupled with a recent prescription or two. While I had health insurance, it really provided me with no advantages other than occasionally reducing the amount a doctor was paid. In effect, I had really expensive catastrophic insurance to protect my aging parents’ assets should I suffer some horrible disease that wiped me out financially (and overwhelmed them with guilt).

Now I pay $475 per month with no deductible. I’ve used my health insurance 3-4 times (plus physical therapy) this year, and my physical therapist now accepts my insurance. In fact he makes about $3 more per visit than I was paying out of pocket. The point is that now my savings occur when I use my healthcare. Before, my savings occurred only when I didn’t go to doctors (because I never exceeded my deductible).

This isn’t the sexiest healthcare story out there, but another example of the incremental benefits of Obamacare.

Another:

Thank you so much for giving me a platform to share my Obamacare success story! Well, actually, it’s my brother’s story and it starts about a year ago.

He was 25 and working for a small radio group in Ithaca, NY. He got into a PhD program at IUP and, since he was barely making any money, he decided to quit his job and spend the summer relaxing and traveling and visiting friends before starting school.

Those plans got thwarted when he was diagnosed with thyroid cancer in June. Three surgeries later, I am happy to say that he is in recovery and doing great, but damn my family would’ve been fucked without Obamacare.

Obamacare let my brother stay on my parents’ insurance, so he was covered when he got his diagnosis. I’m not sure what the costs of his treatment have been exactly, but the bill for just administering the iodine pill he had to take was almost $200,000.00.  When you add all the tests and the three surgeries to that, the costs have got to be close to a million, if not far more.

My family would likely be considered well off, but those costs would’ve bankrupted us. It’s possible that he would’ve been on Cobra without Obamacare, but I think it’s at least equally likely that he would’ve decided to just wait until he could join the school plan because Cobra is so expensive.

At the very least, Obamacare has saved my family from significants costs. And, because he now has a pre-existing condition, it’s the only reason he can buy health insurance and will be able to for the rest of his life.

By the way, my brother purchased his plan on the exchange, before the deadline, and it covers all the doctors he’s been seeing for his treatment. Unfortunately, he doesn’t make enough to get subsidies and PA hasn’t expanded Medicare, so he’s stuck paying the full price. But at less than $150 a month, it’s affordable. And again, at least it’s available.

Another reader:

Count me as another grateful and completely uncounted beneficiary of Obamacare. I work in state government, so my employer health care is about as stable and comprehensive as it gets.

That said, it’s not me I’m worried about; my now-four-year-old son was diagnosed with a tumor growing out of his brain stem in January 2013. The initial MRIs still make me sick to my stomach when I see them – the tumor took up well over 1/3 of the space in the lower portions of his brain, forcing the right side of the brain all the way over to the left. He had three brain surgeries over the span of 10 days and was in the hospital for three weeks. By March 2013, his symptoms were recurring, and a MRI confirmed continued growth. He started chemotherapy immediately, which is still ongoing.

Needless to say, our health insurance has paid for itself many times over. Every day of chemo (which happens once a week) comes with a sticker price of over $6,000. We pay $20. Last year we hit our out-of-pocket maximum for the year by January 7. Our bills would easily be in the 7-figures were it not for insurance.

So why do I thank Obamacare? Three reasons: elimination of lifetime caps (we’d have long since blown past those), under-26 coverage (he can stay on my insurance for two more decades!) and elimination of pre-existing conditions (he can get his own coverage!).Beard

On a somewhat related note, he’ll be done with chemo in 11 days (and 4 hours, but who’s counting?), and it has gone extremely well. His last MRI showed the tumor at the smallest it’s ever been, and strong likelihood that all that is left is scar tissue. He still has his feeding tube, but he’s mostly off oxygen overnight.

When we started this ordeal I shaved my head (he was very excited that we could “match”). I haven’t cut it since, and I also grew out my beard for the first time. I have had to trim that for professional reasons, but it’s all going away soon, so I’ll go ahead and send a picture to unite Obamacare and Beard of the Week (I’ll even throw in a VFYW for good measure!) Thanks for listening.

Thanks for sharing, and great beardage. One more reader:

I’m a farmer, so self-employed, and have been paying for my own Blue Cross-Blue Shield of MN policy since I started farming in 1979. I’ve had a $3K deductible or so all those years, am quite healthy except for wearing out my joints like many farmers, and since my (now former) wife didn’t have benefits, there was never an opportunity to be on a spouse’s plan. This has been a major driver in farm couples’ lives – the spouse who drives many miles for the job with benefits.

I was in a 15-year relationship after my divorce, but we never married or even lived together. My partner worked at Mayo Clinic until recently and had a very good benefits package. I remember one night  7 or 8 years ago she called late and was working on her choices for the plan and said we had until midnight to set me up on her health insurance. Then she called a little later and said since we weren’t married, I wasn’t eligible – unless we were in a same-sex relationship with each other. So I continued to buy my BC/BS plan, and anyway I’m no longer in that relationship.

[Two falls ago] we were busy with harvest until late, due to the weather. I was following the rollout of MinnesotaCare and the problems with the website, plus the national website. I waited for the website to get some of the kinks worked out, knowing I wasn’t eligible for a voucher. I had to turn in crop yield data for the subsidized crop insurance that you and all the other hard-working Americans provide for me, and while at the office my agent asked if I was signed up for health care yet. I said no and he said Blue Cross had a number of plans that were compliant but not on the website. We went over a few in maybe 10 minutes time and came up with three choices, and I left saying I’d call back with my decision. I didn’t get around to it so he called me and I took the middle choice. Same deductible, a few dollars more than I was paying, a little more coverage than I had before. I’m used to a few changes every year anyway and don’t much care about that.

I’ve been getting physical therapy for my right hip since mid-December, and a few weeks ago I learned I need a new one. It’s scheduled for June, after planting season, and with enough time to heal before harvest. Everyone wants to tell me their hip-replacement story now. The one I often think about is Jay Bennett, former member of Wilco, who died of a painkiller overdose. He needed a new hip but didn’t have insurance. He wrecked his hip doing kicks while performing onstage. I wrecked mine carrying pails of pig feed and jumping over gates. But I have insurance, and he didn’t, and I know what that hip pain feels like.

That’s my view from Obamacare.

President Obama Visits Boston To Talk About Health Care

The latest reader thread we want to highlight centers on your personal experiences with the ACA – mostly good, some just okay, a few terrible. Read the whole collection here. Several more of your stories are below, aired for the first time:

I’m 43 and was laid off last year from one of the major banks.  I fell off a ladder about five years ago and ended up having four surgeries to get it all straight.  Besides that, I’ve got ADD and generic meds, but no other major health issues.  I was pretty surprised to be denied coverage by a few companies when trying to get it myself last year.  When Obamacare activated, I was surprised that I got subsidies as a member of the upper-middle class and able to get affordable coverage while looking for a job.  When I did get a contract job, I looked into health coverage.  What the contract company was offering was over twice what I was paying on my own!  The benefits weren’t even that different.  I kept my plan through healthcare.gov and am very happy for it.  For an income around $100k, I figured I’d make sacrifices for the greater good, but I’m actually seeing benefits.

Another reader:

My extended family’s Obamacare success stories come with a huge helping of Republican epistemic closure.

First, the successes.  My 52-year-old brother retired early from working in a manufacturing plant for 30 years and started his own small business.  His house is paid for and he is extremely frugal, so his business provides a comfortable yet modest living.  However, he could not afford to purchase insurance just for himself before Obamacare, so he went uninsured.  Now he pays $53 a month for a plan that is very similar to what his girlfriend has through her employer.  Success!

My niece was able to stay on her parents insurance while she went to grad school for nursing.  Success!

My cousin has a 24-year-old son with spina bifida.  With that preexisting condition, it would have been almost impossible (and unaffordable) to find insurance to cover him once he was off his parents’ policy.  Now with the law restricting insurance companies from denying coverage for preexisting conditions, he will be able to enter the workforce with no worries about his coverage.  Success!

Now the epistemic closure part.  Even with all of these personal examples, my extremely Republican parents have been brainwashed by Fox and still think Obamacare is the worst thing ever to happen to this country.  They are convinced that their Medicare will be taken away and they won’t be able to find any doctors.  They are convinced that President Obama just wants to take all of their money and give it to poor people.  I have stopped trying to educate them with facts and real examples because it is no fun beating my head against a brick wall!

Another:

I am a surgical specialist.  My politics would be RINO, but in this day and age, I vote “not Republican”, as I do not believe the party can be trusted with power nor to govern.

ACA is basically a Rorschach test for partisans.  I’m personally for it as a first step towards a better system, so maybe I’m biased.  I see someone every week who now has healthcare who didn’t before.  Unfortunately, these are often neglected issues that would have been better managed in the past, but at least they have a way now to get care.  I also may be unique because I am uninsurable outside of a group plan due to a personal history of blood clots.  I was turned down by every single insurer despite being fit, no other health issues, and a lifetime risk of clotting again of 8% with no medications or 3% with Coumadin, 10.00/3 month supply.

I practice in a blue-collar area with plenty of uninsured and I’ve watched my income plummet with the economic downturn.  I found that about 1/2 of my head-and-neck cancer patients were uninsured and I had to eat the cost of their treatment – no more; this year so far everyone has had insurance.  Medicaid doesn’t pay much, but it is better than nothing.  The homeless guy I operated on last week came in with his tongue cancer small enough that it hasn’t spread to the neck and his surgery should be all he needs.  That saves the cost and morbidity of radiation therapy.  Sure, he is being paid for by the state, but the cost was much less than what it would have been had he hit the ER in a few months with metastatic disease.

I also had a guy follow up today who is no longer insured since losing his job recently. My right-wing office manager of course blames Obamacare.  I had a gentleman last year who was in the union but for some reason hadn’t been working. He had refused working a certain job since it would have been on a concrete floor, which is hard on his back.  I don’t know the other details, but he had opted to not get his Cobra, and being a 62-year-old smoker and drinker, he has some risks.  He tried to buy Cobra, but he was 20 months out – and of course, he blamed Obamacare for his inability to get Cobra. I don’t bring politics into the mix, but the only reasons he’ll ever get insurance again is because of government programs.  Good luck finding a private insurer who would touch him.

Those who love purely private medicine should ask how would a 78-year-old diabetic with heart disease gets insurance, and what would be the cost?  How does someone with MS get health insurance on the private market if they are single and unable to work?   Look at dental care. (This is healthcare, but that’s another argument.)  A sizable percentage of the population has untreated dental disease.   One-half of my on-call weekends are spent dealing with neck abscesses related to dental infections.  Many of these people are uninsured. And the classic story is they had dental work done, had to pay a bunch of money in cash, developed an abscess, were treated with oral penicillin, got worse and were sent to the ER, where the rest of us treat for free.

I see at least one case a week where the ACA has helped someone get insurance and I have yet to see a case where it hurt.  I am sure there are 25-year-olds who didn’t have insurance and who didn’t have a healthcare issue who are financially hurt, but the fact is, statistically, some of them do get sick, injured, etc … and not having coverage is not acceptable to society who has to eat the cost.  Believe me, I’ve fixed dozens of facial fractures on young men with motorcycles, fast cars, or big mouths who didn’t have insurance.

I also do not understand the greed of many.  I have colleagues who makes 3X what I make yet they feel they are being screwed.  I make a very good living and it bothers me that I see people who are poor and have to do without basic care.  I do not think that everyone should make the same amount of money, and I feel my work is worth more than most, but I also grew up lower middle-class and I can’t fathom not caring that hard working people or children unfortunate to be born to bad parents suffer needlessly.

But another dissents from the others, quoting me:

I’m not sure that “Obamacare is as big a liability for Obama this fall as the Iraq War was for Bush in 2006″, but I do think it will potentially be used as a HUGE negative, even for many who voted for him and other Dems in the past few elections. And I believe that if the Democrats do not quickly grab hold of the reins and prepare well and cleverly and early on to counter what will be the number one issue to beat about the head and shoulders of our candidates, we will most definitely lose the Senate and eventually the presidency. Why? Because many of those hardest hit by the worst unintended effects of Obamacare are middle-class independent and Democratic voters.  And they are feeling betrayed and pissed and afraid for their financial safety.

Most of us who supported health care reform did so out of a sense of empathy and fairness; we were tired of seeing so many people going without decent health care, were angry hearing the nightmare insurance stories in which children were denied cancer treatment, in which the mentally disabled and chronically ill and employed but uninsured got all their care through emergency room visits. We wanted our kids covered longer because college is costlier and taking more time to complete, much less find employment after graduation.  We were tired of having our local communities and hospitals and ERs having to foot the bill for the low-income uninsured, for being forced to absorb the costs of long-neglected conditions that ended up being hundreds, thousand and even hundreds of thousands of dollars when decent primary care could have prevented the illness. We thought it was not only stupid financially; it was morally wrong and wanted to find a way to fix it, smartly.

What we all really wanted, whether we knew it or not, was a single-payer/public option that was affordable and spread out the risk nationwide to make all of our out of pocket costs go down. Instead we got the worst possible “free market” solution they could dream up in DC. 

Far too many of us in the middle class – those of us with one or two job incomes and employer provided health insurance – have been financially REAMED by Obamacare – by the tax changes; by the way this law has been manipulated by our employers and insurance companies to pass on their costs to the individual; by the increase in costs and reduction in benefits in an economy that is stagnant and in which most of us haven’t had a raise in years.  Too many people who supported reform, who voted D, who out here are making moderate incomes and dealing with the competing financial demands of raising families, paying for college costs, helping their elderly parents and now desperately trying to save for their retirements (there are no pensions anymore, don’t forget) are being hurt financially by this law, and unfairly so. And – whether I agree with this or not – it’s all being blamed on Obama and the ACA.

Example: I work as an RN at a medium-sized corporate hospital that offers our employees a really shitty BCBS plan. We staff nurses averaging about $50-60K/yr in earnings and many of them are single parents. I am blessed to be able to opt out due to my spouse having coverage (excellent coverage) as a federal employee, but my friends do not.  Over the past two years, they have seen their deductibles jump to $6000K/yr or more, with co-insurance of 20-30% or more pharmaceutical “co-pays” have jumped to ridiculous levels.

This winter several of my co-workers had to pay almost $60 for a generic albuterol inhaler during their recovery from the various flu-bugs we all got. My coworker’s 12 year-old daughter has juvenile diabetes and she pays hundreds out of pocket monthly for her insulin and supplies. Remember that $5000/family tax-free flexible health savings account we all could sign up for in the past? You know, the one where you set an annual amount to divide up like a loan and put into an account that will advance you the money up to your elective limit for health costs?  Well, “Thanks to Obamacare” it’s been cut to $2500, and believe me that goes fast. One of my coworkers had to take both her small children in for abscessed tonsillectomies and it cost her $3500 dollars, out of pocket,  on our hospital’s wonderful BCBS plan. 

I’ve seen more formerly uninsured people get covered, which is fantastic, but now my hardworking peers approaching middle adulthood with diabetes, hypertension, chronic autoimmune disorders like lupus, funny moles on their skin, obstructive sleep apnea, depression and a whole host of health issue are JUST NOT GOING TO THE DOCTOR ANYMORE.  If it’s not free or catastrophic, they’re crossing their fingers and hoping a trip to the health food store or some meditation will fix their problem.

Yes, they get the low-cost, required “essentials and annual freebies”, but in general, too many of us had better out-of-pocket costs before Obamacare (and even then we were sometimes stretched to pay those).  Since we’re insured by our employers, we don’t meet the stringent numbers to qualify for subsidies on the exchanges, so even if we wanted to opt out and buy there, we’d pay even more in premiums than we do now. I am exuberant that my kids can stay on our health insurance until they’re 26, and that my 29-year-old son would have insurance right now after not having any for four years if he had not finally found a job with it as a benefit.

And I won’t even tell you ALL the ways business is blaming Obamacare so that they can ruthlessly make cutes, refuse raises, and generally squeeze out profit and then dump the hurt on their employees.  At our hospital, ACA is blamed SPECIFICALLY for the layoffs and cost cuts that are hurting the quality of care and safety we offer our patients. They have forced on us increased nurse-to-patient ratios and cuts to CNA caregivers, which has resulted in poor outcomes and even a few serious harms to patients.

Physicians at our hospital are miserable, and spend less time on patients and more time trying to learn and use our electronic medical system . It’s clunky, out-of-date and creates serious errors, but because corporate is cashing in on CMS bonuses in reimbursements by implementing electronic medical records now, they are more concerned about their bottom line than doing it well. So they refuse to purchase better software and the doctors yell and insult and dodge putting in orders (which means WE have to step away from the bedside to do it for them.  Worse, they take their business elsewhere down the road, which in turn results in days off for us due to fewer patients in our unit.

Patients are unhappy and give us poor “Patient Satisfaction Scores” because no one answers their call lights fast enough, so they wet their pants, their food sucks and their rooms are dirty longer than they used to be and the equipment looks like something donated to a Third World hospital in Africa, so they don’t trust it.  My CCU is an oasis of relative safety, mostly due to Medicare reimbursement rules about ratio’s and standards of care, but we are struggling every day and stretched way too thin, and we all worry about the looming “sentinel incident” around the corner that hurts or kills a patient and costs us our license.  Would YOU like your nurse to be distracted from your open-heart surgery recovery because she has to leave your bedside to answer the phone, buzz in visitors, deliver food trays, enter medical orders for cranky doctors, answer call lights for water for other patients, and cant get your emergency cardiac iv’s because her computer system has crashed once again? I don’t think so.  

Anyway, this is just a long, frustrated, but hopefully insightful, rant about the day-to-day NEGATIVE impact of ACA has been, and why it will be a big challenge to overcome in the next two election cycles. I really wish we had more focus on THESE kinds of issues and how they will be remedied, and fast because it scares the SHIT out of me that we’ll end up getting an entirely radical Republican national government if we don’t. And there’s no Meep Meep if that happens.

Update from a reader:

Your allegedly sympathetic but frustrated RN asserted that “because of Obamacare,” Health Savings Account minimums have been “cut” to $2,500, and folks can’t sign up for robust HSA accounts anymore. Well, I knew that was bull as soon as I read it because I have an HSA for my kids and me, to which I contribute $4,000 annually. So I Googled the issue. The IRS issues the annual HSA minimums and maximums, which I don’t see has anything to do with “Obamacare” – have a look.

So this RN is using the HSA minimum and representing that as the maximum that “Obamacare” appears to allow. The truth is, anyone with dependents could sign up for as much as $6,550 in HSA contributions in 2014! (That figure is verified here.) And it’s going up another $100 for 2015.

Another:

The respondent discussing HSA limits as quoted by the IRS is discussing a health savings account, which has different limits and is continuable through successive years, as opposed to the Flexible Spending Account as discussed by the RN. The FSA is a tax-differed method to pay for out-of-pocket expenses for health plans without high deductibles. FSAs expire at the end of each year, with any unspent money evaporating. So, in a sense, they are both right, but talking about different beasts.

(Photo by Yoon S. Byun/The Boston Globe via Getty Images)

The Schumer Consensus

Andrew Sullivan —  Dec 2 2014 @ 12:32pm

Sen. Chuck Schumer

You can barely click on a link these days without reading someone arguing that Obama’s decision to pursue healthcare reform in 2009 – 2010 was the fatal flaw of his administration. As Chuck Schumer put it, putting healthcare before economic recovery sent the wrong message to working-class whites, who have been fleeing the party in droves ever since. Today, Charlie Cook offers up the same message about white flight:

An argument can be made that it is because Democrats have subordinated their traditional focus on helping lower- and working-class Americans move up the economic ladder in favor of other noble priorities, such as health care, the environment, and civil rights.

I’ve heard this a million times now and I simply don’t understand it. In terms of chronology, Obama did put the economy first. With TARP and the stimulus and the auto-bailout, the key measures to shore up a flat-lining economy were taken in short order. You could plausibly argue, I think, that in retrospect, Obama should have gone bigger, and produced a much more ambitious stimulus. But, as someone who observed this close-up and in real time, the odds of that actually happening were close to zero. And if it had happened, the stimulus would have been even less popular – and more easily demagogued – than it actually was. The problem was not the timing or the seriousness of the response; it was the seriousness of the problem. When an economy has a near-death experience, on top of huge public and private debt, the recovery will tend to be exactly what this recovery was: long, sad at first, and later … well, we don’t know yet, do we?

More to the point, healthcare was itself a response to the wounded economy. Here’s why. It’s very hard to see how the white working classes can ever see the kind of income gains they enjoyed for much of the mid-twentieth century in the new global economy. Tax redistribution can only do so much to counteract the enormous forces depressing those wages. But one way in which the working poor can tangibly be helped is by providing access to health insurance, something everyone needs, and something that costs a huge amount for a struggling blue-collar worker. You could argue – and I would – that universal health insurance in America – is actually the most effective measure available to counteract soaring social and economic inequality. Far from being a distraction from the core Democratic task of helping the working family, it’s one of the most effective policies for that goal that’s available.

I suspect that what is really going on is a matter of perception – which, of course, does matter in politics.

The healthcare debate in 2009 and 2010 was more spirited and fierce than the debates over many other issues. The GOP decided to make it their first boogeyman of the Obama years, and organized the 2010 mid-terms around it. And politically, especially against a typically feeble Democratic messaging campaign, that made cynical sense. Even though Obama had put the economy first, the GOP could alter the debate to make it seem as if he had put healthcare before jobs. And since his healthcare proposal was successfully distorted by the right as a redistribution scheme from the white elderly to poor blacks and browns, you can see why this might lead to white flight.

My point is not that this didn’t happen in the public consciousness. My point is simply that this wasn’t because of Obama’s skewed priorities. And to blame Obama for the distortions and demagoguery of the ACA on the right is to cement the cynics’ victory twice over. But that’s what Democrats of Schumer’s era always tend to do. It’s the kind of defensive crouch that the Clintons perfected over the years. What Obama deserves criticism for is not the substance, but the inability to sell and explain and communicate the core principles and purposes of the ACA. He was so busy trying to get something through the Congress he took his eye off the ball in public opinion. And since there appears to be almost no one in Democratic ranks who can make the case except Obama, it turned into a political failure.

But that, again, is not a foregone conclusion. We are still in the very early stages of the ACA’s existence, the period when opposition is likely to be strongest, when glitches remain, when the benefits have yet to be fully or widely felt. Sure, the polling has been relentlessly negative since the ACA was passed – but that is not unusual for new and large government programs. If the economy continues to improve in the next two years, moreover, the impact might begin to reach those white working classes who increasingly view the Democrats as alien. And if the ACA brings tangible benefits to the struggling poor who are its primary beneficiaries,and as the minimum wage debate continues, the politics of class might shift again. When the debate is about removing health insurance from large numbers of the working poor – as the Republicans propose – the self-interest of the white working class might begin to work in the Democrats’ favor.

Well, we’ll see, won’t we?

(Photo: Senator Chuck Schumer waits to speak at the National Press Club on Tuesday, November 25, 2014, on what went wrong for Democrats in the 2014 midterm elections and what they must do to succeed in 2016. By Bill Clark/CQ Roll Call)

Chuck Schumer is second-guessing the Dems’ decision to prioritize the ACA:

In his harshest assessment of the Obama presidency to date, Schumer argued that the White House and congressional Democrats erred by focusing on the Affordable Care Act throughout most of 2009 and early 2010 rather than following the passage of the economic stimulus with other targeted economic legislation that would directly help more people. He said voters had given the party a mandate in 2008 to stop the financial crisis and reverse the economic damage done to the middle class, and while he supported the substance of Obamacare, it was a political loser because it offered its most tangible benefit—access to coverage for the uninsured—to just 5 percent of the voting public.

Beutler disputes Schumer’s version of history:

The health care reform process didn’t begin in earnest until after the Recovery Act had already passed, at which point Congress’ willingness and ability to pass another big deficit-financed stimulus bill had been maxed out. Maybe Schumer has other ideas in mindlabor rights? Housing policy? A different entitlement?but he’s never laid out what the achievable alternative was, and how the middle-class and Democratic Party would’ve been better off as a result.

That’s because there never really was an alternative. Not that Democrats couldn’t have done a better job helping the economy recoverI believe they could havebut that the One Big Thing they cashed their capital in on wasn’t really up to them. Health care reform was basically pre-packaged, and ready to go because that’s where the consensus was. If after such a decisive victory and once-in-a-generation majorities, Obama announced he would go small on health care reform, or put it off for another time (like he did with immigration reform) the backlash would’ve been severe. It would’ve been his first major elective move as president, and it would’ve splintered his coalition very badly.

Weigel argues along the same lines:

There’s an alternative history of the Obama years in which the administration, like some time traveller sent back to fight Skynet, prevented the Tea Party from ever being born. It governed from the populist left; it owned the fight against “Wall Street” and denied the right the ability to side with the proles by opposing TARP. It’s a widely held belief on the left that this really could have been done, with smarter hires and less concern for the financial world that was going to turn against Obama anyway. Obama could have, like FDR, “welcomed their hatred.”

The small problem with this argument is that it’s bonkers. The Republican opposition to the new Obama presidency did not begin with the ACA. It began with the economic stimulus bill, which Democrats had hoped to get as many as 80 Senate votes for, and ended up scraping through with only three Republican votes in the Senate and none in the House.

Steve M. disagrees:

But Obama, even after the stimulus fight and the rise of the tea party, had enough juice to get the health care bill passed, because that’s what he’d saved the rest of his political capital for. That was the make-or-break agenda item for him.  And of course he was going to prioritize that rather than a larger stimulus — he was an ambitious president with an eye to the history books. A bigger stimulus wasn’t going to be the accomplishment that made his name as a president — for that he needed a big piece of legislation.

Except that what Obama is going to be known for is failing to help the middle class enough in the wake of the crash. I favor the health care law, but it’s porous — it doesn’t help enough people, and there are many people it doesn’t help at all.  What if stimulus and debt relief had gotten the make-or-break treatment from the White House?

Waldman is unimpressed by such arguments:

[T]o say that Democrats shouldn’t have bothered on the off chance that they could have passed some more stimulus and maybe minimized their losses in 2010 makes one wonder what the point of electing Democrats is.

Schumer would reply, “To help the middle class!” But when he got to the point in his speech where he was ready to offer all his terrific ideas for doing so, he punted, saying, “I’d like to outline not WHAT policies Democrats will propose but rather HOW we should build our party’s platform to appeal directly to the middle-class and convince them that government is on their side.” What followed was some mundane PR advice.

That’s something there’s no shortage of, and, to put it in Schumer’s terms, the voters didn’t hire him to dispense messaging tips. If he really wants to help his party, he ought to get moving on those middle-class proposals he keeps talking about. When do we get to see them?

A reader sighs:

What is wrong with this administration when it comes to their healthcare overhaul? They cannot be this dumb:

Under current rules, consumers who do not take action during the open enrollment window are re-enrolled in the same plan they were in the previous year, even if that plan experienced significant premium increases. We are considering alternative options for re-enrollment, under which consumers who take no action might be defaulted into a lower cost plan rather than their current plan.

So the administration that spent an unconscionable amount of time fighting claims that the ACA was a government take-over of healthcare are considering allowing HHS to take over certain people’s choices for their health insurance. There are no words for how stupid of an idea that is and whoever thought of it should be forced to watch Fox News for a week non-stop until they get the picture.

Another is far more optimistic:

The autorenewal mess … isn’t going to be a mess.  Do you think the people who signed up last year are stupid? They are on the ball, and they are used to shopping. Thirty years of deregulation has taught all of us to check around when a CD comes due, when auto insurance renews, and during open enrollment at  work, and most importantly, when your mobile phone is out of contract.

If you can do your taxes, you can handle this.

And if you can’t, there are people (insurance brokers) who will do it for you – just like there are accountants who will do your taxes for you.  I work in the health insurance industry, for one of the Blue Cross/Blue Shield affiliates, and we are already seeing signs that insurance brokers are all over this. Not all of them, but the smart ones certainly are.  They will be reaching out to their clients, I guarantee it.  There is an incentive; a new policy pays a higher commission than a renewal. So there is a significant financial incentive for the broker to put their customer in a new plan every year.

The reason Obamacare is so rickety and so complicated is that it uses the existing system.  Rather than providing single pay, it depends on a patchwork of state-level insurers; there is no federal market for insurance.   Even the biggest companies have to file their plans at a state level, which is fiendishly complicated because what is OK with one insurance commissioner can be sent back for amendment by the state next door.  If you are a red state living next to a blue state, well … it can be frustrating.

But the genius in the plan is that it greases all the right palms.  The providers are guaranteed payment after decades of writing off uninsured medical – there is now in effect a stop-loss of the amount of the insured’s out of pocket, so rather than eat $50,000 in costs for a hospitalization, the provider will eat the first $12,000 worst case, with the insurance company covering all above that. The insurance companies are given a captive market, and the brokers make money too.  It’s a win all around for private enterprise.

I will be very interested to see what happens if the Supreme Court rules against the federal exchange.  I am guessing the pressure will be on Congress to amend the statute or cede the powerful health care industrial complex to the Democrats for all eternity.

Certainly there will be a few people who fall through the cracks and will be paraded around on Fox News.  Those people deserve the same amount of sympathy as somebody who claims they thought they could just file their taxes once and then the government would take care of it for them – after all, their taxes are coming out of their paychecks.

While total repeal of healthcare reform isn’t in the cards as long as there’s a Democrat in the White House, Brett LoGiurato predicts that “the overall GOP strategy will likely be to chip away at parts of the law in bills that could make it to the president’s desk”:

A full-repeal bill would certainly prompt a presidential veto. One item Republican House and Senate aides think is likely to make it to Obama’s desk, and potentially get his signature, is a bill to repeal Obamacare’s tax on medical devices. A similar amendment, championed by Sen. Orrin Hatch (R-Utah), who is in line to become the next chair of the Senate Finance Committee, passed by a 79-20 vote in 2013. “I think the med-device tax and some other little areas would be the best place to start, because that is the ‘possible,'” a senior GOP aide on the Senate Finance Committee told Business Insider of Republicans’ pursuit of Obamacare-related legislation in the next session of Congress. Republicans could also take aim at so-called risk corridors in the health law, a potential fight that some Republican senators have already begun discussing as part of a shutdown battle.

Cohn wonders whether the new Senate will try to kill the individual mandate:

Of all the proposals Republicans might pass, this is the one that would probably threaten to wreak the most havoc.

Economists say that the requirement to get health insurance (or pay a fine) entices lots of people, particularly young and healthy ones, to buy insuranceand, in so doing, keeps premiums for everybody else lower. If their projections are right, then taking away the mandate would mean more people without insurance, and higher premiums for those who hold onto it. Obama, a skeptic of the individual mandate during his presidential campaign, eventually decided the economists were right. He’s fought to keep the mandate ever since and there’s no reason to think he’d back off that position now. But the provision is unpopular with the public and Republicans might be able to pick up enough Democratic votes to pass a bill, just to force a very public veto.

The GOP’s statehouse victories are also bad news for Obamacare, as the newly elected or re-elected Republican governors aren’t likely to move forward on expanding Medicaid and might well tinker with or scale back existing expansions:

In Arkansas, where Democratic Governor Mike Beebe pioneered a way to use Medicaid expansion funds to subsidize private coverage, the future of that program is in doubt under the incoming Republican governor, Asa Hutchinson. Republican leaders in moderate states have expanded Medicaid, including Rick Snyder in Michigan (who won last night) and Tom Corbett in Pennsylvania (who lost). Republicans taking over in blue states, including Illinois, Maryland, and Massachusetts, may seek permission from Washington to revamp those Medicaid programs to make them look more like the privatized versions in Arkansas, Indiana, and a handful of other places.

Overall, Gerard Magliocca concludes that the ACA “is still not settled law”:

While Congress cannot repeal the Act over the President’s veto, the issue will remain a live one through 2016.  More important, the election results may influence the Court’s thinking on whether to take the cert. petition in King.  Court watchers noted the other day that the petition was relisted, which is often (though not always) a prelude to a grant.  The timing of the relist to correspond with the midterm election may be a coincidence, but in any event the election result may embolden the Justices who dissented in NFIB to take a statutory crack at the Act.

Meanwhile, Igor Volsky glosses over the GOP’s other likely legislative targets:

Republicans promised to force approval of the Keystone XL pipeline — a project 16 senate Democrats endorsed when the body voted on a non-biding resolution in March of 2013 — and have pledged to pass a budget in both chambers. Rep. Paul Ryan (R-WI) — the likely chairman of the House Ways and Means Committee — has promised to tackle tax reform (a project he told Bloomberg on Tuesday night would ideally attract 60 votes in the Senate) and insisted that Republicans still plan to advance immigration reform — on a step-by-step basis that begins with border security. Obama endorsed such a process last year. Other issues with bipartisan support include an insistence that the administration submit any deal to stop Iran from developing a nuclear program to Congress and approving fast-track authority for trade deals with the European Union and nations in Asia.

Correction from a reader:

One of the quotes on your recent post on the ACA at the state level said the following: “Republican leaders in moderate states have expanded Medicaid, including Rick Snyder in Michigan (who won last night) and Tom Corbett in Pennsylvania (who lost).” Former Governor Corbett did not actually expand Medicaid. He submitted his own privatization plan to the federal government, but it was never approved or enacted.

Ester Bloom fumes:

Wal-Mart has decided to cut benefits for PT workers, even though the Wal-Mart empire has produced so much money that individual Waltons take up four spots on the list of Top 10 Richest People in America. Christy Walton is the 6th richest American with a fortune of $38 billion, Jim is 7th with a fortune of $36 billion, Alice is 9th with $34.9B, and S. Robert is 10th with $34.8. Come on guys.

Peter Suderman attributes Walmart’s change to failures of Obamacare:

You can see the kind of impact the law is having just by looking at the news. Walmart is dropping health plans for about 30,000 part-time workers, about 5 percent of its workforce, according to the Associated Press. Target, Home Depot, and other big retailers have made similar moves. The retail giant isn’t specifically citing Obamacare as the cause. But it’s almost certainly a factor.

Paul Waldman disagrees. He claims that “this development is actually a good thing, and it shows that the Affordable Care Act is working”:

So why is this a good thing? It may involve some hassle for individual employees, as they’ll have to go to the exchange to figure out what plan to get. But most of those Walmart workers will likely come out ahead. Someone who’s earning $9 an hour working 30 hours a week at a Walmart would be making $13,500 a year. Depending on what their spouse makes and what state they’re in, they could be eligible for Medicaid and pay nothing at all for insurance, or get substantial subsidies that would make a private plan extremely affordable.

Sarah Kliff also argues that the shift should be celebrated:

[F]inancial help [from the ACA] can be a big deal for those with lower incomes. Think of the 36-year-old Walmart employee here in Washington, D.C. who works 29 hours per week at the company’s average wage of $12.73 per hour. She earns just about $19,000 annually if she works every week of the year.

If Walmart doesn’t offer her insurance, the Kaiser Family Foundation’s subsidy calculator shows that she qualifies for a $1,751 subsidy from the federal government to help buy coverage on the exchange. With that financial help, she can buy insurance for as little as an $7 per month. As a low-wage worker, she gets some of the most generous financial help.

But if Walmart does offer her coverage, it becomes her only option. She doesn’t qualify for federal help and the $7 plan disappears. Walmart’s plan, meanwhile, is way more expensive. The average premium there works out to $111 per month.

David Graham views the move as simply a sign of the times:

Take a step back and this story looks like another milestone on the changing road of the American health care system, even if there are only 30,000 employees affected by this particular step. And it looks more like a symptom of the same underlying issues that inspired the Affordable Care Act, rather than like a result of that law. In announcing the move, Walmart cited the rising costs of health insurance. Big companies are seeing their costs rise, but they also don’t have to worry as much about keeping their employees well, since they can be sure that they’ll be insured through exchanges anyway.

Health-policy experts and wonks on both the right and left tend to look askance at the American system of employer-based insurance, which is essentially a historical accident. (They differ on what do in the post employer-based-insurance world, of course: Progressives want a universal national insurance system, while conservatives want individuals to deal with it themselves.) As more and more American workers leave employer-based insurance plans, for one reason or another, the end of this anomalous system seems closer and closer.