Obamacare Created Big Medicine | Hacker News Reader

Obamacare Created Big Medicine

mattstoller.substack.com

29 pointsconnor1152828 comments

Jimmy Carter doomed universal health care in the 70s. He promised it when he ran for president in 1976, but then his administration dithered and delayed, worried about the costs, proposing incrementalism instead. Ultimately, Senator Ted Kennedy, author of his own universal health care bill, got so tired of the delays, backtracking, and broken promises that he ran a primary challenge against Carter in 1980, which failed but may have doomed Carter's chances in the general election.

Carter ran as an outsider, and his problem as President is that he was an outsider, alienating his own party, making him largely ineffectively, and leaving him with no base of support anywhere.

Democrats could have passed universal health care when they had a filibuster-proof super-majority near the beginning of the Obama administration, but Obama himself was kind of an outsider and quite a political novice, having served less than one term as Senator. It's a joke to call it "Obamacare", because Harry Reid and Nancy Pelosi did practically all of the negotiating and heavy lifting, while Obama himself was mostly MIA during the debate. (Not to mention, the Obama administration completely botched the ACA rollout.) And the Democrats bent over backwards to water down the proposals to get Republican votes, but they ended up getting precisely zero Republican votes anyway, despite the fact that their bill was basically Romneycare.

  > despite the fact that their bill was basically Romneycare.

Romneycare was a plan built for one particular state, one of the main problems with the ACA was trying to replicate that state-based plan across 50 states that all have various systems.

Eh the Democrats never really had the supermajority needed to pass Universal health care because the super majority depended on Joe Lieberman.

Joe Lieberman famously made them drop the public option in order to get his vote:

https://amp.theguardian.com/world/2009/dec/16/joe-lieberman-...

They always have an excuse.

Anyway, the filibuster can be abolished at any time.

The Democratic supermajority in the late 70s was nuts.

The leaders decided to push through “deep changes” without consulting the base. The result was things like the ERA.

They knew they had to placate centrists - so did things like outlaw federal funding for abortion and random deregulation nobody (especially the deregulated industries) wanted.

Which pissed off their base.

Plus the very unfortunate economic situation did not help.

The biggest results was a bunch of ex-Democrats and a very left wing judiciary.

B.S. this was happening way before the affordable care act was passed.

Further, like any massive new legislative program, there are plenty of improvements that can and should be made over time, no one can get everything right the first time. But we all know why every opportunity to make even slight improvements to ACA has been deliberately rejected.

Matt Stoller would never let a fact get in the way of hating the Libs.

I'm pretty much "the Libs". I view the ACA as guaranteeing private health insurance companies a future instead of granting them the death penalty like the country needs. Even so, I read through the entire article without once thinking "wow, this really is critical of Libs." What in particular would you characterize as "hating the Libs"?

> I view the ACA as guaranteeing private health insurance companies a future instead of granting them the death penalty like the country needs.

It was a step in the right direction at the time. We’ve done nothing to improve upon it since then because one side has spent the last decade trying to destroy it and the other seems mostly ok with our system as it stands.

I don't know if it was a step in the right direction. It helped people in a very real way, my family included. But that was maybe the only shot we will have for the foreseeable future to unfuck our healthcare system. Who knows when the political will to really shake things up in healthcare will come back.

If there's one thing I've learned about American politics in my adult life, it's that large changes like "unfucking" our healthcare system do not happen over night. It takes incremental changes over many years, perhaps decades. That definitely wasn't going to happen in 2010, and shouldn't have. We can't just destroy the private health care system tomorrow, it would have massive economic implications.

It wasn't the only shot, we just need more politicians that want that change and are willing to not be so stubborn to try to do it fast.

I am not asking for it to happen over night, that's silly. What I'm asking for is effective plans that don't just further enrich politicians' private healthcare buds, executed when the time is right. Medicare for All would have worked and would be mostly implemented by now. Instead we still have an expensive trash heap.

Not getting rid of an incredibly wasteful system because it negatively impacts the economic status of the people it unfortunately employs isn't even conservative thinking, especially when it's such a huge drain on the economy. In this case it even kills people. Why are we letting them hold everyone hostage? Why are their jobs more important than having affordable or quality care for the entire country? It's not a fucking jobs program! It's healthcare!

It sort of puts the blame on one part of the ACA, but even if you find that distasteful or not compelling, the rest of the article is very interesting and informative.

Yes I had a similar reaction. I've been involved in healthcare long before the ACA, and my family before that, and I thought it was absurd to tie any of these trends to Obamacare. Pretty much everything decried in the piece was on track long before the ACA, in the sense that even if something occurred after the ACA, it was predictable from trends prior to the ACA.

I'm also tired of all the focus on insurance and payment, and not on the monopolies (monopsonies?) in health care provision. We can focus on payment all we want but if we don't open up healthcare services to real competition and innovation prices will continue to go through the roof with declining returns.

I give some credit to the piece for somehow touching on that issue, but it's superficial and again tied to insurance and payors.

It's infuriating being on the inside of all of this and seeing the way it usually is discussed in policy forums. It's like everyone wants everything to remain the same but be cheaper, and that's not going to happen.

What does it take to open it up? You can't get to competitive pricing without transparent pricing, which you can't have with our opaque payment system. No one can tell you how much something is gonna cost, even after services are rendered, until much later usually with a bill in the mail.

With how dysfunctional healthcare is, you'd think if real competition were possible we'd already be seeing disruption in this space. That's not happening! The most obvious culprit is the private payer, so that's a natural place to look.

A lot of the problems come from Medicare acting like a central planner that doesn't regulate prices for people outside of their system.

Like my local hospital is blessed, it runs an ER in an area with few hospitals, so Medicare pays it at a higher rate for all care. But Medicare also won't make an agreement to pay for care if someone tries to open up a competing hospital (and investors know this, so they won't bother trying to compete), and they don't tell the hospital that they have blessed that it's not okay to charge ridiculous prices to other customers.

"the market" is why we're in this situation. The healthcare cost crisis is simply not a problem that capitalism has any mechanism to address.

Capitalism balances supply and demand by modulating prices. When demand is above supply, prices go up until demand drops. When supply is higher than demand, prices go down to bring demand up. But demand for healthcare can't go down. There is no force opposing price increases, so prices must tend toward infinity.

When it comes to life-or-death situations, people will pay just about anything. The market will bear almost any price, and the entire operating principle of capitalism is to increase prices to the limit the market will bear.

There just is no mechanism by which capitalism can consider the value of human life. Otherwise we wouldn't have to write laws to prevent children being maimed in factories, or prevent people selling snake oil as a miracle cure, or create entities like the EPA to prevent companies poisoning entire towns. The only solution is for the government to intervene and cap prices.

The only reason you'd ever lower prices for healthcare is because it's the morally right thing to do. Capitalism does not recognize the concept of morality. There is no internal force which could lower prices, so it must be an external force.

I guess I can kind of understand why you think demand "can't go down." But I have no idea why you ignore the possibility of supply increasing.

Exactly. I'm from Gen-X and the author's assertion is patently false and conveniently ignores everything that happened prior to the Obama admin. Besides it was Republicans that deregulated the medical industry among others and removed limitations on how much market share any single company can control. This is what led to the mass market consolidation and mega-conglomerates we have today.

I started following Matt Stoller a long time ago when I found out about his anti-monopoly stuff. Then I started following on Twitter recently and yikes — it made me question how much undeserved credibility I had mentally assigned to him. He regularly says some pretty unhinged uber-confident things that are completely outside his lane.

> The dominant trend of US social life over the last fifteen years is a stagnating, and then declining, life span. There are many reasons for this trend, such as violence, diet, suicide, drug addiction, and auto accidents.

Americans are less than half as likely to have a fatal car accident today than they were in 1970. Violent crime is way down too.

How do I read the substantial claims in this article when these simple false claims are tossed out in passing?

Addressing the specific claim of last 15 years. Annual auto deaths per 100K population in the most recent 15 years of NSC data:

2005 15.3

2020 12.9

That's a lot, but it's not an upward trend, and the long term trend is down since 1940.

https://injuryfacts.nsc.org/motor-vehicle/historical-fatalit...

> I want to offer that one key part of our health care problem is a simple conflict of interest, which is letting payers and providers be owned by the same entities.

Combining payer (insurer) and provider (hospital/clinic) appeared great for patients. It aligns the interest of keeping the patient healthy (so they keep paying premiums), and costs are kept low (no pointless/dangerous diagnostics or interventions). As a customer of Kaiser Permanente, I couldn't be happier. Feels totally natural that I pay for someone to keep me healthy, and they do.

But having read the article, I'm wondering if Kaiser Permanente is structured different from UHG/Optum, creating different incentives, and leading to the problems discussed. Or maybe they’re just less greedy than UHG?

> and costs are kept low

From the outside looking in, I have to admit that the article's reasoning makes a lot more sense than this claim. They can raise prices and there's nothing the client can do but pay higher premiums.

That Obamacare accelerated the trends may be true. However, I can’t think of too many government reforms that actually improved healthcare generally. For instance, W’s prescription drug program increased drug costs for a lot of seniors. Previously, a relative of mine received her most expensive drugs free of charge through programs administered by the drug companies themselves. Afterwards, many of these programs went away, transferring the cost back to the consumer and ultimately the taxpayer.

> The two firms leading the charge here were UnitedHealth Group (UGH) and CVS

Bit of cheeky a Freudian slip here

If vertical integrations were prohibited, wouldn't that mean Kaiser has to break up?

Reply on news.ycombinator.com