The ten year anniversary of the Healthcare.gov rescue
pauladamsmith.com
pauladamsmith.com
36 states initially did not set up their own exchanges.[0]
It appears that currently, 20 states (including D.C.) have their own marketplace.[1]
>The shutdown prevented anyone from outside the main team working on HealthCare.gov from coming in to help
That government shutdown in 2013 was instigated entirely by one U.S. Senator, Ted Cruz, expressly for the purpose of sabotaging ACA.[2]
[0]https://aspe.hhs.gov/reports/health-insurance-marketplace-pr...
[1]https://www.healthcare.gov/marketplace-in-your-state/
[2]https://www.texastribune.org/2016/02/16/ted-cruz-2013-obamac...
Sometimes the stars align and the federal government builds a system that is actually nice to use.
But sometimes the system is a steaming pile of shit.
> But sometimes the system is a steaming pile of shit.
I'm pretty sure I've seen the same outcomes in private business too. Just look at the history of Windows, as one of very many examples.
States opting not to open their own exchange (grey): https://en.wikipedia.org/wiki/HealthCare.gov#/media/File:ACA...
States opting not to expand Medicaid (blue): https://upload.wikimedia.org/wikipedia/commons/4/47/Medicaid...
(The second chart had more blue at the time; opt-outs have gone from 26 down to 10 now.)
I'm glad they're not smart enough to do that though and people were able to get healthcare through the federal exchange. I hope these bigots continue to be evil and dumb, if they get smart then we're really in for a bad time.
Y'know the ACA originally had a public option in the bill. Guess which side killed that? Why did we even need an ACA-with-private-insurance-companies anyway? The ACA was initially copy of what was implemented in Massachusetts by Mitt Romney. It's frustrating that Democrats had to compromise just to end up with a system that only somewhat better than what it replaced, and then get blamed for the result.
It’s not a frustrating outcome of democracy. It’s a failure of democracy with one party trying to take over and destroy all other opinions by all means necessary, which includes an open revolt and election stealing.
> It’s a failure of democracy with one party trying to take over and destroy all other opinions by all means necessary
Lots of people talk shit but almost everybody is still going about their daily lives in a normal civil manner. Obviously the state of American democracy could be better, but don't pronounce the patient dead just because he tripped and got his knee bloodied.
But this particular one? Not so much. Vastly better ones elsewhere, if only because they have less veto points and a better amendment process.
The bulk of it was largely designed around the specific circumstances of them 13 colonies->states, many of whom kind of hated each other, and full of appeasements to their different concerns at that time. Everything else has been retrofitted into it since then.
Which ones?
Canada? Japan? Australia? Germany? Even places with significantly unpopular governments like France and the UK don't have a situation where one of the houses of government can't function.
I think if the Italian government is more functional than the US then it's time to realize there is a real problem.
Here's a list of countries by GDP[1]. I'm looking at it and struggling to find a country that is (a) developed[2] and (b) a democracy and (c) doing worse in terms of functional governance than the US.
Turkey and Thailand are two options where they had attempted or actual coups, but neither are classed as developed.
[1] https://www.worldometers.info/gdp/gdp-by-country/
[2] https://www.oecd-ilibrary.org/sites/f0773d55-en/1/4/3/index....
There is neither a Constitutional nor a rational basis for a special unique exemption for past Presidents, and fortunately state and federal prosecutors seem to recognize that.
Sure, but using criminal process or any other power of office to punish partisan enemies is a problem whether or not the target is a past leader; there's no special danger around past leaders. if anything, there is less danger around past or current high government officials in general, and past Presidents in particular, because of the extraordinary degree to which those persons tend to be visible and well-connected politically.
Indictments on 91 felony charges across three different sovereignties in four different proceedings is...not what most people would describe as zero consequences.
(Also, there are several other active state criminal investigations relating to the fraudulent electors scheme, some of which have produced criminal charges against other people and any of which could very easily also result in further indictments for Trump.)
While I believe in due process, justice delayed is not justice.
And the body that should have sanctioned him (the elected government) voted down any punishment.
Pointing fingers is getting us nowhere. Someone needs to behave rationally and neither side is willing to do that. I don't really care who the worst offender is, we just need someone to step up and not be an offender
[1] https://www.healthsystemtracker.org/chart-collection/u-s-spe...
The group responsible for the actual legislation was the Affordable Care Today Coalition which consisted of a lot of different interests:
https://www.wbur.org/news/2007/04/10/affordability-clash-wbu...
To be clear: he shouldn't have voted against it. But if the Republicans wanted good outcomes neither should any of them.
https://publicintegrity.org/health/elimination-of-public-opt...
https://slate.com/news-and-politics/2009/10/did-sen-joe-lieb...
I think it's a mistake to view the two parties as representing two distinct ideologies, and further to believe either parties rhetoric about what constitutes their ideology.
Most of the game of US politics is to see how many terrible/unpopular deeds you can perpetrate against the public on behalf of the moneyed interests (not voters) that supported your campaign without losing votes to the opposition.
Wedge issues and propaganda keep people voting on party lines for candidates that only occasionally act in the majority interest of their own voters, let alone the interests of the greater public.
I love the irony in your bigoted comment.
California has a good system that is roughly standalone while NY has one (also good) that is integrated into other NY programs. Both fan out into a network of actual humans (mix of private and public sector) that help make it work for people who for whatever reason can't use the online service. It's hard for the feds to do something like that at scale -- for example to have it integrate into other lcal programs.
At least, I had much more faith in my state government (MA) to not half-ass this kind of thing.
See also, NEVI, where the government is spending billions of dollars to build chargers via a complicated system involving state managed programs. It was passed almost two years ago and hasn't deployed a single site.
If so you might not be qualified to be a republican governor.
Wouldn't it be much better to hire your friends as IT consultants, make broken systems as confusing as possible, and continuously change the rules, and then starve the half-assed system of funding in an attempt to keep people from signing up for coverage at all? What makes this plan doubly republican-friendly is that all players are your donors and most victims are minorities.
The federal money is an extortion scheme.
The way federal programs nominally work is that people with money pay taxes to fund the programs. The people with money disproportionately live in certain states, which is the justification for making it a federal program -- then you can have a uniform national program even if some states don't have the tax base to provide it themselves.
But then the representatives from the states with money make it so the federal government doesn't fund the entire program. This benefits them first because they can shift some of the tax burden from the rich taxpayers in their state to the poorer taxpayers in some other state where any of the program's beneficiaries are. It tries to force every state to fund part of the program from their own tax base even if the people in that state didn't want it, because the alternative is to pay the federal taxes anyway but not get any of the federal money.
Then it benefits rich people again because the rich states, of course, implement the programs and get the federal money, but any state that refuses the scheme that disadvantages them is still paying federal taxes and gets nothing. So now you're getting a transfer of wealth from poorer states to richer states -- a penalty the representatives from the richer states intended when they constructed the program that way.
But the poorer states may not have the money to fund the state's portion of the program, and in any event refusing it is the only way the state government has to protest the federal program being constructed in that way. It puts pressure on that state's federal representatives to reform or remove the program.
So don't blame the poorer states for not implementing the program, blame the richer states for passing it without funding it.
Residents who do not have private or public health coverage still get health care. They go to the ER when they need help and they receive care in the most transactional and expensive way possible. The cost for this care is paid by all the other residents who do have private care (via higher prices) and in their taxes.
The goal of Medicaid is not to pay for more care, it is to better organize the care that is being provided, and in doing so, improve outcomes and lower the overall cost.
One reason Medicaid expansion has seen steady adoption, even in “red” states, is that earlier implementations have shown that this happens and the program is a net improvement.
Implying that a federal program is unnecessary because the states would have the incentive to do something anyway, but could then tailor the program to the geography and economy of their state instead of having something imposed on them that was drafted by Washington lobbyists.
> The goal of Medicaid is not to pay for more care, it is to better organize the care that is being provided, and in doing so, improve outcomes and lower the overall cost.
The problem is not that the patient pays otherwise, it's that the state if they want to implement Medicaid and get the federal money their tax base is paying taxes for regardless, has to put up even more money only to have the federal program dictate how they can spend their own money. That's the extortion -- they remove money from the state's tax base and only give it back if the state provides even more money and implements the program under the federal terms.
It gives the state no opportunity to make their own choices, which might have been more cost efficient. It destroys the "laboratories of democracy" the federal system was intended to have before lobbyists found a bunch of ways to cheat the constitution and take everything over centrally.
> One reason Medicaid expansion has seen steady adoption, even in “red” states, is that earlier implementations have shown that this happens and the program is a net improvement.
The main reason is because states can't afford to run their own equivalent program under their own terms when the federal government is raiding their tax base and then only returning the money with strings attached -- one of the major ones being that they have to spend even more of their tax dollars on the program whose terms are dictated by the federal program.
And this is not the only federal program that operates this way. So much of the poorer states' budgets go to spending money in order to get federal tax dollars under federal terms that they can't afford to do something different. Both accepting and refusing the money leaves them with not enough resources to do something on their own -- if they refuse it they end up with less money than they started with because tax dollars leave the state only to fund the program in other states, but if they accept it they have to pay even more and lose the ability to make their own choices.
It's unsurprising that many states would knuckle under to that level of coercive pressure -- the coercion is the intent. Otherwise the program would be a block grant, or simply not exist at the federal level so that federal taxes would be lower and state taxes higher, allowing similar programs to be operated by the states.
Notice that of all the people who downvoted that comment, not a single one attempted to defend having the program as a coercive centralized mandate from the federal level -- which was the criticism -- and instead the only argument is that a program of that nature is good. But whether the general idea is good or not is a separate question from which level of government should construct it.
Especially when it turns out that a lot of people the money is coming from aren't actually rich, and a lot of the "people" the money is going to aren't poor people at all but major corporations.
Many state elected leaders, however, have strong individual incentives to avoid any change that exposes previously hidden costs to their constituents, because then their opponents can accuse them of raising spending and/or taxes. (Even though they all know the cost has been there hidden all along.) This is the same incentive structure that inclines state politicians against spending state money on environmental protection, workplace safety, infrastructure, and many other areas where the federal government ends up taking the lead.
You seem pretty plugged in and sympathetic to the point of view of state elected officials. The idea that federal taxes are money stolen from states, for example, is a classic state politician talking point.
But I think you might be surprised how many federal actions are secretly supported by state officials who publicly campaign against them. They get to benefit from the material improvements delivered by the federal program, while blaming Washington for out of control spending, unfair coercion, etc.
But this is just defending the general concept of such a program, not a reason it has to be constructed at the federal rather than state level.
> Many state elected leaders, however, have strong individual incentives to avoid any change that exposes previously hidden costs to their constituents, because then their opponents can accuse them of raising spending and/or taxes.
How is it that federal elected leaders are immune from this incentive? And if they are, isn't that bad, because they would then for the same reason have no incentive to implement programs efficiently?
> The idea that federal taxes are money stolen from states, for example, is a classic state politician talking point.
It's a straightforward economic effect. Bob earns his wages which are then spent by some combination of Bob, the state government and the federal government. If the federal government takes more then the state government and Bob get less, and Bob is going to be in a bad way if there isn't enough left to make rent.
Meanwhile if the federal government uses the money for Medicaid then the state doesn't have to collect the money the federal government spends on it, but then it's the federal program setting the terms -- and if the state doesn't like those terms, Bob still has to pay all of the same federal taxes. The state can't use his money to operate their own program instead.
Federal spending is currently ~25% of GDP, which is more than it is for most states -- and a huge chunk of the money attributed to states is the state portion of the money required to implement federal programs. By the time you also pay for state programs whose funding couldn't reasonably be reallocated to something else, there is nothing really left. The states have lost the ability to try to do better because the federal government has locked up all the money.
> But I think you might be surprised how many federal actions are secretly supported by state officials who publicly campaign against them.
Well of course they do. They're opportunistic politicians. If they can't reasonably implement useful programs because the money they'd have to spend is already going to the feds then their remaining option is to claim credit for not spending it.
The point is, what would happen if the states were actually left with both the problems and the resources to solve them?
That’s because you completely misunderstand how government bureaucrats think. You’re not paying for it - the taxpayers do
I have money and the desire to transact and I cannot. The system is a failure.
Also, if the website is broken, you should be able to call and talk to someone to get a plan. Not ideal but it's not like you're completely out of options.
The phone support just leads to a ticketing system that responds via the web app. You can’t log into the webapp from foreign IPs without locking out the account (which can only be unlocked via the phone number on file, which only supports US mobile numbers and not Google Voice). They don’t use email. If your autopay credit card expires, they cancel your policy without any notice but paper mail, which is insane in 2023. They won’t let you reinstate it, even if you backfill pay your unbilled months.
It only works for people with a single US number who get their paper mail on a regular basis and never travel for long periods of time. I live in Europe half the year and the service is unusable.
I long for an actual free market in this shit.
FWIW the IRS operates entirely over paper mail.
(Not sure why, I suspect is that paper mail is more expensive for fraudsters.)
Yes, they use paper mail to set up your account, but the idea that the IRS remains limited to the exchange of paper is wrong.
Source: a USA citizen living in Canada, with a USA tax accountant who submits my returns and paperwork electronically every year since 2010.
Like if they discover a problem with your return.
"You should be able to" do a lot of things that you cannot actually do.
So much for being a "free" market when it's only open for a month each year.
I went looking for articles about this recently and couldn't find them any more. Did I imagine this happening?
More people in the pool makes costs more predictable, and more healthy people in the pool makes them lower. The loss lf the individual mandate driving them out made costs less predictable and on-average higher, and higher rates themselves increase opt-outs, reinforcing the effect.
I'm not sure what the basis was for state marketplaces for the ACA but the history of involving states seems to make everything worse. Adding an intermediary allows programs to be scuttled and money diverted (if not outright stolen) by other programs and participants.
As an example, Texas refused free money from the Federal government for Medicaid expansion, amounting to $5-6 billion per year [2].
[1]: https://www.cbpp.org/research/income-security/lessons-from-t...
[2]: https://www.statesman.com/story/news/politics/politifact/202...
I doubt Texas refused on this principal, but states viewing Federal money as free is irksome. It's not free. It's a hidden tax on both your current citizens in terms of devaluation of their savings, and future citizens to pay off the debt the Feds are creating with this "free" money.
Talking about inefficiency - it'd probably be significantly more efficient to stop requiring this money to funnel through DC. But it's more about power than efficiency.
(Well, some do, but not the cheap way.)
There are no unfortunates in the USA, there are only losers and winners.
Also if you look at GDP measured in PPP the US doesn't really have an advantage. In other measurements as HDI they trail even behind
We don't live in a black and white world where Medicaid alone is the answer to all our problems. If anything, these centralized mandates have caused significant price increases and less competition, in multiple sectors, including thr currently apparent housing shortage and affordability crisis.
...really? You do?
You think Texas turned down federal money equal to 0.05% of the state's GDP because of the inflationary impact?
Refusing government aid on principle is literally a campaign slogan in Texas.
IIRC, in 2013 Republicans had control of the house and didn't pass a new annual budget. In the last few weeks of the year they did pass a continuing resolution saying something along the lines of "continue the government funding for 2 months at last year's levels until we pass a more complete new budget, and also repeal the Affordable Care Act". The Senate voted in favor of most of the continuing resolution but not the ACA repeal, which caused deadlock when the HoR and Senate couldn't reconcile the 2 versions of the bill that passed.
It didn't, and they're still mad about it.
You say it like it's a bad thing. ACA is horrible -- extremely expensive, few options, huge deductibles, virtually zero transparency, "keep your doctor" turned out not to be true in many cases.
I'm no Ted Cruz fan, but I wish more people had stood up and admitted this thing was a total piece of shit and tried to prevent it from passing.
All thanks for a single server (with one backup) using Jekyll, if I remember the story correctly.
But they probably will eventually add a compensating bonus for critical work the way they had to do with medical doctors. Physicians that work directly for DoD make an enormous bonus compared to others in the same pay grade but different career field because otherwise they wouldn't be able to hire anyone. They react slowly but eventually react.
What you're talking about, though, is a problem with procurement procedures. It's far easier to get through Congress than any change in operational budget that involves increased pay for federal employees, even if the outcome is otherwise identical. And it frankly makes sense to a large extent. Even if they have to pay way more for a private workforce, they only have to justify it for a several year project. Hire the same number of civil servants and you're committing to employing them for the next 30 years. They need to know they'll consistently have work for them to do. They can't just institute mass layoffs and hiring spurs on the other side the way industry can.
I mean, ok? 20 years ago is a long time. As you say, pay is now like ~1/3 that of industry, and the pension doesn't make up for it.
> What you're talking about, though, is a problem with procurement procedures. It's far easier to get through Congress than any change in operational budget that involves increased pay for federal employees
Wait, is raising the pay of federal employees considered "procurement"? If not, aren't you agreeing that procurement of software consulting services is an end around the main issue, which is that wages of federal employees are too low (a non-procurement issue)?
Not really. All my job offers started with "This is at-will employment".
Yes, employers may fear lawsuits from entitled employees, but it's actually not such a large risk as general public believes.
The U.S. federal version is the U.S. Digital Service, which regularly advertises in the HN “who is hiring” threads.
I think this may be what you are thinking of. To my knowledge that site was entirely replaced when the federal exchange launched, and there was not a serious challenge serving the landing page since it did not take in or process any personal data. It was only once you started trying to find a plan that everything ground to a halt.
Development Seed also developed another project you may have heard of: Mapbox. (To which they eventually pivoted the entire company.)
I thought that was really clever, and filed it away as something I'd use in an emergency in the future.
It also reminded me of a WebTV incident with a database overload. I came up with the idea of shutting down all our last-hop mail delivery servers, which needed a database connection. That caused email to queue in the SMTP inbound Servers, which we drained later when the database was no longer overloaded.
The lesson is: use batch-oriented processing from queues to take load off of systems that are designed to work in a transaction-oriented manner, but are failing to do so.
I remember 10 years ago when HN tore apart the website's source code on GitHub: https://news.ycombinator.com/item?id=6540993
It's like a little bit like engineering "competency porn", but I enjoy stories like this. I read The Phoenix Project a few years ago, and while it was fictionalized and a heavy handed introduction to Agile and DevOps (I'm a data analyst so it was new to me), I liked it, and would like to read anything similar, if anyone has any recommendations.
Here's one good excerpt:
Dickerson quickly established the rules, which he posted on a wall just outside the control center.
Rule 1: “The war room and the meetings are for solving problems. There are plenty of other venues where people devote their creative energies to shifting blame.”
Rule 2: “The ones who should be doing the talking are the people who know the most about an issue, not the ones with the highest rank. If anyone finds themselves sitting passively while managers and executives talk over them with less accurate information, we have gone off the rails, and I would like to know about it.” (Explained Dickerson later: “If you can get the managers out of the way, the engineers will want to solve things.”)
Rule 3: “We need to stay focused on the most urgent issues, like things that will hurt us in the next 24–48 hours.”
You screw up a contract, you're banned from all government contracts for the next 10 years. Simple. We would have actual working technology instead of a churn of garbage.
Just rename the company. Or shuffle the teams.
XML database ? For a critical service used by 300 M people?
Brrrrrr.....
I suspect business rules in XML, so effectively read-only, while dynamic data in a rdbms ? Maybe that's just my hopeful heart talking :-)
[0] https://lobste.rs/s/igt4ez/10_year_anniversary_healthcare_go...
[1] https://en.wikipedia.org/wiki/MarkLogic
[2] https://lobste.rs/s/igt4ez/10_year_anniversary_healthcare_go...
The other gotcha was Java is single inheritance. Foo > XML. Bar extends Foo > XML. Baz extends Foo > /dev/null the Bar bits in the persistence layer.
The MarkLogic bits did OK. When everything went sideways at launch, almost no traffic was getting all the way to the back end. Because things were getting profiled, there was way more time to tune and tweak the indexes as they tried to re-engineer things. The NoSQL bits helped there, as it made it a bit easier to morph things as it was refactored.
Not to say there were not pain points or they did not have a silly amount of hardware in it in the end.
One of the more memorable things for me was working in the XOC, having an update go sideways in the early AM, and seeing CNN pop up a ticker saying ACA was down. Good times.
Source: I was also a member of the Tech Surge. (Paul Smith recruited me to help with testing.)
That page is unsurprisingly manicured and free of any “controversies” section.
""" There's lots more at the wikipedia article on healthcare.gov, in particular CGI's poor performance on a Massachusetts state website, which at least one report "characterized as a complete failure... The software created by CGI was of poor quality and unusable" (that from the wikipedia article) That may or may not be true, but it should at least be mentioned here. Instead we have (as you say) what appears to be an advertisement from CGI's PR department--still, years later. Mcswell (talk) 19:22, 20 July 2023 (UTC) """
[0] https://www.amazon.com/Recoding-America-Government-Failing-D...
• The six employees sued included five executives at the vice-president level and higher, as well as a technical manager who was accused of having conducted a fraudulent demo of the new system's capabilities.
• The state sought "only" some $45 million from the technical manager, as well as amounts ranging from $87 million to $267 million from various Oracle executives.
(It seems likely that the state sued the Oracle people personally to "encourage" them to cooperate in the discovery process in which the state presumably sought documents, etc., from Oracle. This happens a lot on the criminal-law side of the docket, where it's known as getting defendants to "flip" and testify against their co-defendants. The past couple of days have seen examples in the Georgia RICO case against former president Trump.)
High-profile lawsuits like this typically settle before trial. Not least, this is because the elected officials who bring or authorize the lawsuits would prefer to trumpet a "victory" instead of rolling the dice with the court.
And sure enough, Oregon's lawsuit against Oracle was settled — Oracle agreed to pay Oregon $25 million in cash and to provide the state with another $75 million in technology. [1]
(Copied largely verbatim from my course materials.)
[0] https://web.archive.org/web/20141014060142/https://www.orego...
[1] https://www.oregonlive.com/politics/2016/09/post_183.html
... securing their future income.
If I bought such a bad burrito from a vendor that I had to sue them, I'd probably stop buying from that vendor.
In retrospect, maybe we shouldn't worship "heros who drop in, save a project, then leave", especially if it leads to non-sustainable lifestyle for the heros, or creates further technical debt that makes it hard for contractors to develop sites.
As for non-sustainable lifestyle, it differs from person to person. It's an appointed position of 2 years, with one chance of renewal for that reason. It's an unique opportunity to see the government from a position of power, so it's expected for USDSers to try to make it count.
It's not always the case USDS will create further technical debt for contractors to develop sites. During cutovers, consider creating playbooks and provide context in those non-stop meetings to the contractors, and best of all, provide a phone number and an email for emergency.
And some of those people from USDS never left the government. ;)
But there's a reason why all democrats are still running for federal office on a platform of healthcare reform. It won't be repealed after the supreme court upheld it and the republican congress under Trump gave up on trying to repeal it after McCain's no vote on repeal.
There isn’t a realistic chance of repeal. Both of the main political parties here benefit from it too much: the democrats by claiming a health care win, which our latte liberal class eats up, and the republicans by having an additional hot button issue (like abortion and guns) to whip their lunatic fringe up with. Not to mention all the campaign and lobbying money from private insurers who are profiting immensely off of ACA.
I might add at the expense of the middle class who now have much higher premiums with much higher deductibles.
It's also important to remember --- though I don't think it changes any of the fundamentals of the issue --- that the ordinary "retail" care that we access on a year by year basis, including short hospital stays, isn't where all the cost in the system is.
Provider networks have local quasi-monopolies. Insurers are price takers.
I'm against socialize health insurance, but what we have today is just as bad though in different ways.
Yes. This is one of those frustrating areas where economists and experts across the political spectrum are in near-unanimous agreement, but anybody who tries to move the system in a sane direction gets attacked for "taking away your insurance". The ACA doubled down on employer mandates, when it should have used the exchanges as an opportunity to get people off employer-based plans.
I'm against socialize health insurance, but what we have today is just as bad
As I've often said, we've managed to combine the worst aspects of both markets and central planning with the benefits of neither.
This was the point of the Cadillac tax
https://www.kff.org/health-costs/report/2023-employer-health...
> I'm against socialize health insurance
You have directly contradicted yourself.
Personally, I'd rather we figure out how to have at least some real baseline of public healthcare, but what we have today feels like the worst of both options.
And honestly the fact about flood insurance even if it’s true is only an implementation detail.
The point stands: you can have strong insurance markets with multiple private options in a well regulated environment without being tied to your employer or just a public option.
Being forced to pay for something to share the cost across a set of people is the definition of socialized. The implementation detail is that it’s shared by all purchasers of insurance as opposed to the population as a whole.
> The point stands: you can have strong insurance markets with multiple private options in a well regulated environment without being tied to your employer or just a public option.
There is no such market for flood insurance.
I don’t think it’s possible to fix the US medical insurance system without banning corporate health plans. It’s the only way to unify the risk pools. Not just removing the tax incentive for corporate plans, I mean banning the concept so that the pools are unified.
For some definition of socialized. I would argue that a transaction between two private entities in which there might be a minimum ceiling for some items is not “socialized”. Even if the minimum ceiling is enforced by the state.
We can argue all day about definitions but at the end of the day nothing is black and white: even if we agree that there’s some “socialized” extent in the private car/home insurance markets I think most would still not say that it is “socialized” in general.
Regarding flood insurance, yes, agreed, there’s no natural law that says that flood insurance must be a profitable business (hello global warming!) so the government steps in.
https://news.gallup.com/opinion/polling-matters/169541/name-...
This is how you get weird shit like Trump making vague promises at rallies that sure sound like a call for some kind of stronger ACA or even single-payer healthcare. Many aspects of those things are broadly popular—the propagandized-against labels for them, however, are unpopular in some circles, especially if promoted by a person with the wrong letter next to their name.
https://www.newsweek.com/barack-obama-donald-trump-obamacare...
https://www.theatlantic.com/politics/archive/2011/10/who-coi...
We should have kept calling it RomneyCare.
What are costs like for unsubsidized plans now?
Before the ACA went into effect, the main focus that everyone talked about was on the individual insurance market: in particular, trying to fix the adverse selection issues that had kept the individual insurance market in a continuous death spiral. ACA tried to fix that with the "Three Legged Stool": guaranteed issuance (no longer could a pre-existing health issue be denied coverage), government subsidies for people who couldn't afford it, and the individual mandate (everyone has to buy insurance or pay a fee) to make sure people didn't free-ride while healthy and only get insurance when they were sick. There was also a side project, which was this was that subsidies for really poor people turned out to be really expensive, so perhaps it would be easier to have everyone below a certain threshold just get Medicaid (government insurance for poor people that for complicated historical reasons is largely federal but partly each individual state funded- this is distinct from Medicare, which is entirely Federal and offers universal coverage to everyone over 65). So everyone can use the exchanges to get insurance, if they don't get insurance they have to pay a fee in their taxes at the end of the year, and Medicaid had expanded eligibility rules to cover more people. Health care wonks largely expected the exchanges to do most of the work, and some of them even envisioned a future where the link between jobs and health care were broken- your job pays you more money and you get insurance on your own through the exchange. But that was a future dream, for the ACA itself the focus was on just getting the exchanges to run. That is what healthcare.gov was all about, matching you to your local exchange and offering you the right plans and subsidy amounts- tying together insurance companies, the IRS for your tax returns, and state IT systems all together.
Then the conservative-controlled Supreme Court surprised many, and upheld the ACA exchanges on a 5-4 vote, though they added a random restriction never found before in any Supreme Court ruling that each state would have to accept the Medicaid changes on their own- a rewriting done by the Chief Justice's clerks in haste (after he apparently changed his vote late in the game to allow the rest of the law to stay, the liberal wing joined him immediately, no matter how weird it was, much better than losing the whole thing).
Now a decade on, the exchanges have proven to not be very popular- everyone who can still gets their insurance through their company because it is seen as a better deal than going through the exchange (because of corporate consolidation on both the insurance company and medical provider sides there is actually very little competition in the exchanges, so the prices didn't go down as expected). Far more people are covered by insurance than before, but it was almost entirely because of the Medicaid expansion- slowly over time even red states have gotten into it, and now only 10 states are still holding out, even as their rural hospitals are utterly devastated and many are forced to close because they can't get paid for their work (in order to balance the budget within the act, some of the US government programs that used to support poor people without insurance were ended- they'll all have Medicaid, so are unnecessary- except then the Supreme Court's rewriting meant that many poor people don't have Medicaid, and the GOP views even attempts to fix things for their own states as a step too far). The individual mandate- which had been viewed as essential to the success of the exchanges- was zeroed out by the Republicans when they took power, that is, the fee for not having insurance was set to 0. And it didn't really have much noticeable effect, because the exchanges didn't make much difference in the end, the power turned out to all be in the Medicaid expansion.
This in turn is what has driven the more liberal health care wonks towards single-payer and BernieCare and the like: if the exchanges didn't have much impact and Medicaid did, why not just make Medicaid-for-all?
This is a rather strange interpretation, because the marketplace was never intended to compete with or replace employer provided insurance. In fact, the ACA has an employer health insurance mandate for companies with at least 50 employees. The marketplace is primarily for people who aren't otherwise covered by employer health insurance or Medicaid, such as the self-employed, and I suspect that the marketplace is used by most of those people, especially because of the income-based subsidies.
Ok, but... how are the dreams of "policy wonks" relevant? What we got is what Congress passed, and what Congress passed preserved and enshrined the role of employers in providing health insurance. Thus, the fact that people who have employer-provided health insurance are not on the exchanges doesn't seem interesting, given the actual laws in place (as opposed to some imagined future alternative).
And I think you're underestimating the number of people who don't have employer-provided health care and who do use the exchanges, especially with the so-called "gig economy".
> This is why Congress and their legislative staffers are the only people who do have employer subsidies on the exchange
Congress granting itself an exception is just par for the course.
From 2020:
> As the Affordable Care Act, or Obamacare, turns 10 years old on Monday, the health care law is as popular as it has ever been, according to new numbers from the latest NBC News/Wall Street Journal national poll.[1]
> Forty-two percent of all registered voters believe the law is a good idea, compared to 35 percent who think it's a bad idea, while 23 percent don't have an opinion.
* https://www.nbcnews.com/politics/meet-the-press/ten-years-la...
On political lines:
> Eighty percent of Democratic primary voters, as well as 72 percent of all registered voters who describe themselves as Democrats, say the Affordable Care Act is a good idea.
> That's compared to 72 percent of Republican voters in the poll who say it's a bad idea.
* Ibid.
2022:
> Public opinion of the Affordable Care Act (ACA) has been largely divided along partisan lines since the law was passed in 2010. Following Republican efforts to repeal the ACA in the summer of 2017, KFF Health Tracking Polls found a slight uptick in overall favorability towards the law, and since then a somewhat larger share has held a favorable than an unfavorable view. The most recent KFF Tracking Poll conducted in March 2022 found slightly more than half of the public (55%) hold a favorable opinion of the ACA while about four in ten (42%) hold a negative opinion of the law. Views of the ACA are still largely driven by partisanship: nearly nine in ten Democrats (87%) along with six in ten independents (58%) view the law favorably, while eight in ten Republicans (79%) hold unfavorable views. Explore more demographic breakdowns using our ACA interactive.
* https://www.kff.org/health-reform/poll-finding/5-charts-abou...
Loss column: Insurance rate increases still bonkers and unsustainable (IOW at some point, it’ll get high enough to force some kind of big shift or reform, with a lot of suffering and economic damage along the way). No public option. Not all plans are on the exchange (this varies state by state). Even “gold” plans are kinda shit and insurance still tends to cover less each year, even as prices increase. Fewer insurers offering individual plans at all, at least in some states. Healthcare spending in general still stupid-high and getting higher. Whole thing’s still very complicated, adding costs all over the economy and putting a significant time-burden on sick people and families of sick people, all for no reason whatsoever except protecting a bunch (a whole bunch) of middlemen’s jobs.
https://publicintegrity.org/health/elimination-of-public-opt...
https://slate.com/news-and-politics/2009/10/did-sen-joe-lieb...
There are some charts of health insurance costs over time [1] here. These charts look the same pre-ACA and post-ACA. Costs continued to rise at about the same rate has they had before.
[1] https://www.kff.org/report-section/ehbs-2023-section-1-cost-...
The pre-existing condition coverage part is really important for us.
The problem with all health insurance is the opacity of actual costs. 80/20, deductible, out-of-pocket, these things are not trivial and they wander all over the place. Add to that the seemingly random prices charged by healthcare providers, which are even less understandable as "adjustments" are made.
Nobody has any idea what anything costs. Healthcare providers throw out a number, see how much they get back, and call that the price. It's absolutely insane. The only way you can get this level of brokenness is to combine government, big corporations, and a powerful middleman lobby and let them figure out how to run things.
All this nonsense to avoid "socialized medicine."
Worse, nobody seems to have any idea how to fix that.
For the problem of high costs we can at least take a look at what other first world countries do for some idea. Most are spending well under 1/2 of what we spend.
For the problem of increasing costs though we can't look at others because they too have increasing costs comparable to the rate of increase of US costs.
For example, in 1980 the per capita health costs in the UK, France, and the US were (in USD) 385, 659, and 1036.
And here is what the costs were in those countries in 1990, 2000, 2010, and 2018, divided by that country's 1980 costs:
Year UK FR US
1990 2.0 2.2 2.6
2000 4.1 4.1 4.4
2010 7.5 6.1 7.7
2018 10.6 7.5 10.2
2.1 Germany
1.8 France
2.0 Canada
1.7 Italy
2.6 Japan
2.6 UK
2.3 US
I used 2018 instead of 2020 because I did this calculation a few years ago, and 2018 was the latest data at the time. My source now has data through 2022.
1. Go to https://data.oecd.org/healthres/health-spending.htm
2. Uncheck "latest data available". This enables the year range selector control.
3. Use the year range selector to expand the range to cover the years you are interested in. They have 1970-2022.
4. The chart will then show the total costs in US dollars/capita by year of health care in 50 countries. You can use the "Highlighted Countries" drop down to narrow that to select a "background" of OECD, EU, Euro Area, G7, or G20 if you want. You can then add individual countries using the list on the left of that dialog.
5. You can change what is shown from total to government/compulsory, voluntary, or out-of-pocket and you can change the measure from per capita to % of GDP.
It was just for me, a healthy(ish) man in my 20s. The year was $200 a month. The next year was $300 a month. The next year was $450 a month.
It had some good in it, such as not denying people based on pre-existing conditions (along with the limited period you can get insurance). Capping how much insurance companies can make as a percentage of revenue was a real poison pill that only served to make costs balloon. They have no reason to be more efficient, or to try to clamp down on healthcare costs. The more we all pay, the more they make, and it's their only path to do so apart from taking marketshare from a competitor.
I think we'll probably end up with single-payer sometime, which will be a real mess and a huge amount of money will be wasted for decades. We could fix the insurance system, but it'd be politically unpopular:
Everyone's insurance is insurance again. By that, I mean it doesn't cover routine care (apart from a yearly physical, just to encourage that), medications, etc. It's all very high deductible, possibly with some sort of low income subsidy (that still shouldn't go too far).
Providers need to publicly list prices, or give good faith estimates for things that aren't routine.
Cap medication prices to an average of...Canada, UK, Germany, and Japan - or some other list. This wouldn't be needed for cheaper drugs but for the ridiculously expensive ones that'd normally eat up your high deductible in a month.
Bam. Done. There'd be a few years of pain, but you'd quickly see healthcare prices drop off a cliff as consumers would suddenly care that their clinic's sleep study costs $7,000 when the place an hour away only charges $1,500, or that they can do testosterone injections for $20 a month instead of taking a pill that costs $500 a month.
https://www.cbo.gov/budget-options/2013/44890
Single-payer is unlikely in the US for many reasons, if you're interested in the topic though the CBO did a thorough look at all of the different things that would be required for such a system:
https://www.cbo.gov/system/files/2019-05/55150-singlepayer.p...
Still in startups, from 2016-2022, my company switched brokers with the exception of 2 years to get teaser rates. We're looking at a new broker this year to avoid a 9% increase.
The problem is that companies are penalized for long-term thinking. Why pay today when in the future it may be someone else's problem. That creates a sort of tragedy of commons among insurers. No one is insurer wants to pay today, but everyone would be better off if all insurers paid. That's a known market failure so some government intervention is necessary to improve market efficiency.
Unfortunately healthcare ticks a lot of other "market failure" boxes in its mode of operation. So it needs to either be heavily regulated or socialized to prevent market failures driving prices up and efficiency down. Don't believe me? Ask any economist that studies market failures.
She didn't know what the ACA was, which kind of surprised me, but she definitely knew what "ObamaCare" was and changed the subject after realizing that she had wasted money on screenings because she assumed that she had no vision coverage.
It astounded me how many people hated "ObamaCare" but had positive views of the Affordable Care Act. Even today I think that it would be political suicide to repeal the ACA.
I believe they voting mccarthy out in the first place was only possible because of the dems' votes
Poor? It is awesome, your healthcare might be ~$40/mo
Work for a huge company? you're indifferent to it.
Self-employed? It is terrible, your rates skyrocketed. Trash bronze plans can cost you >$500/mo and barely cover anything. Good plans will be closer to $1000.
> Testing was largely a manual process. Releases and deployment required lengthy overnight downtimes and often failed, required equally-lengthy rollbacks. The core data layer lacked a schema. Provisioning hosting resources was slow and not automated. Critically, there was a pervasive lack of monitoring of the site. No APM, no bog-standard metrics about CPU, memory, disk, network, etc., that could be viewed by anyone on the team.
If you know how to do it without being indicted anyway.
Constant back and forth change orders, pointless delays to serve constantly changing stakeholders, constant demos with no real product, no one in the customer with any power who has experience to call BS on timelines or delivery, etc.
And if done correctly, everyone in the ‘customer’ is simultaneously happy and angry and so it’s easy to deflect blame and point fingers back into their own org.
Or so I’ve heard from folks who are involved. I try to avoid it like a plague, the BS I deal with hurts my soul enough already.
The federal government is a big beast, though, so it takes a while for the idea to spread.
If leadership isn't careful (and it seldom pays to be careful), it becomes an excuse for every real wrong.
And they failed at that too. Apparently what would have been a weekend project for a high school student was so hard for a federal agency that they burned $3.1 billion trying to do it. (This level of incompetence is truly despicable.)
I wonder if there is something pathologically wrong with government and how government (at least in the U.S.) does spending.
I just think it’s a shame that it’s politicized because we can’t easily discuss it as a case study without pre-existing political opinions creeping in. It would be neat if this particular series of events could be dissected in a vacuum. Government projects go sideways all the time but there’s a lot of transparency into why this one did because of the unique circumstances of its resolution.
Both sides of the aisle have patrons that feed at this trough and I doubt we'll ever get consensus better operational insights and less waste and fraud.
Like so many other issues, the only thing holding us back from achieving this is will.
People should be free to vote for someone that best represents them, without worrying about a spoiler effect or strategic voting practices.
There's plenty of input to consider on how to improve things, we just need to find the collective will to act on it.
https://www.brookings.edu/articles/reforming-federal-procure...
It's estimated that US healthcare per-capita spending is 20% more than countries who use a single-payer program (that's nearly every other developed country in the world).
We can guess the reasons - everyone and their dog wanted to be part of the flagship IT project, a slew of conflicting interests and parties who would not talk to each other or in some cases were actively sabotaging efforts, a failure to recognise that "working complex systems only ever evolve out of simple working systems".
Why do we always do this to ourselves ?
I was a support engineer working with an Enterprise Service Bus. I represented my company and took part in some diagnostic activities.
At the time, I had political reasons to oppose the ACA, so taking part in the fire-fighting was against my personal politics. I gave it my very best effort. I regard it as one of the finest moments of my career.
Also I hope that some academic historian has been in touch to catalogue that notebook!
I appreciate the author resisting that framing, and admitting that on that first day, the contribution of the new team was basically to ask "Can we install New Relic on the servers?" The response to that question really illustrates the root of the problem, in my opinion. It's not that the people who built the original healthcare.gov were stupid people. It's that they were operating under constraints and incentives that emphasize rules and compliance over making the whole system work well.
They also make websites which have excellent color contrast and intuitive design, and you can tell that a lot of thought went into each one.
Great comment. I spent the first half of my career in classical "silicon valley", direct-to-consumer businesses. Lately, I've been working in software in highly regulated industries. The differences between the two cannot be overstated. Even if you look past tiny (/s) issues like "you can't lose people's money, ever", you've got reams of often-conflicting regulations at the local, state and federal levels. Making a small text change to a webpage can require multiple lawyers.
This kind of well-intentioned stuff sometimes makes it impossible for the greatest engineers to do even simple things quickly. Work at the government level, and it gets worse, because now you have politicians reacting to your every change.
Obama brought in Mikey Dickerson, head of google SRE, as well as several top people in Facebook (at least those were the people I had directly heard about) and humbly said "we failed, we need your help." From what I remember hearing he literally brought top valley people into the oval office and gave a "your country needs you" speech.
"Install new relic" really minimizes what was actually happening. "Can we install this tool that helps us understand how the system works" sounds a lot more enlightened doesn't it? Understand what's broken is the first step to fixing something and that's exactly what "installing new relic" does. If you don't have a monitoring system, that shows an extremely critical failure of technical leadership. It means no one knows what's happening. No one is measuring how things work. The google SRE book devotes chapters to monitoring, probably 25%+ of the book is explicitly about monitoring.
If you listen to Mikey present his work on healtchare.gov, he does not emphasize the solution, he emphasizes the problem: No one knew how things worked, no one knew how the pieces fit together, no one could measure why the site was performing so poorly.
The step after "installing new relic" was getting 50+ contractors in the same room and making them justify themselves. The contractors sold themselves to the government, but there wasn't a person on the government side with enough understanding to know you don't need 3 different load balancers at the same level for the same traffic and every system does need monitoring. How many different data stores do you really need?
If you listen to Mikey Dickerson give his presentation live, to the people he hopes to recruit, then it was very poorly managed at the technical level. Were those people stupid? probably not, but they were giving out lucrative contracts to any company that said they could help. So the makers of the original healtchare.gov (and by proxy the American public and Obama administration) were being taken advantage of for their ignorance.
> It's that they were operating under constraints and incentives that emphasize rules and compliance over making the whole system work well.
It's that trust was given to American companies who directly benefited from taking advantage of the government, and not to individuals who work on behalf of the public with specific expertise.
Mikey ends his presentation with a powerful call to action. If you aren't going to help the government with your own expertise, and make that sacrifice on behalf of the public, then some contractor will happily fill that role.
Good points but that sounds to me like too simple a story. The people managing healthcare.gov weren't working their first day or managing their first project; you don't get that job without some experience. And if you have some experience, you know what you don't know, you know how to deal with those situations.
(I'm not implying some other specific story - I don't know what happened. I'm just wary of such simple answers.)
He also said there was no culture of real-time monitoring. They literally had a TV running CNN, and whenever the chyron said "healthcare.gov is down again" they would spring into action. Amazing.
Thats very kind of you but they probably were, if not stupid, then just large companies who routinely do these big government websites and mess them up and only just get them done years late and way over budget and don't really give a shit or face any consequences.
This NPR article says the original site was built by a bunch of different companies, most of them subcontracting out to other companies, and no-one really in charge of the overall architecture apart from some little subsection of Centers for Medicare and Medicaid Services who probably weren't ready for the cat herding required.
https://www.npr.org/sections/alltechconsidered/2013/10/25/24...
I can tell you that the difference between a site made the 'Silicon Valley' way and an 'enterprisey' site made by EDF or Acccenture or Fujitsu or one of those other big companies is a massive difference. Its a completely different world.
It's quite improved, IMHO, especially from where things were in 2013.
There are still some shitty things out there, like the National Parks lottery, but things are improving.
Right, and thats because USDS and 18F kick out all the big old 'enterprisey' consultancy companies and bring it more in-house. And presumably the smarter version of in-house where you hire people who can actually do stuff. Digital Services Coalition sounds like a sortof in-between where companies can apply to join but presumably they are finding ways to avoid the crap old enterprisey ones.
You go to the doctor, there is no one else there, because there's no need for paperwork. The doctor just types your name into their system and that's all that's needed.
My son was born there. Total cost: 0.
Same son had a minor tumble once, but proceeded to have one of these, which absolutely scared us to death: https://en.wikipedia.org/wiki/Breath-holding_spell - we called an ambulance because his lips were a bit blue. He started breathing again just fine as we called, but they sent it anyway.
Total cost: 0. And it was nice not having to think about that when we made the call. It got there very quickly and they took him and my wife in to check him out in any case, just to be sure.
There are a lot of things I like about life in the US, and things that didn't work well in Italy too, but the health care system was just nice in that it's just there and you don't have to screw around comparing confusing plans and worrying about it being attached to your job.
You can read more about this if you look up Tammany Hall.
Much of the cost of doctors in the US comes from expensive insurances doctors need to take against malpractice lawsuits. Even when people are informed of the risks when they partake in a medical procedure, they want to blame somebody when the risks materialize. People need somebody to blame when something goes wrong.
There was of course a drop for COVID-19, but progress in life expectancy basically stalled after ACA was implemented, whereas life expectancy has kept growing in every other developed country.
https://www.washingtonpost.com/health/interactive/2023/ameri...
And to be clear: "While opioids and gun violence have rightly seized the public’s attention, stealing hundreds of thousands of lives, chronic diseases are the greatest threat, killing far more people between 35 and 64 every year, The Post’s analysis of mortality data found."